Provider Demographics
NPI:1699264655
Name:TRACEY H NGUYEN OD - PROFESSIONAL OPTOMETRIC CORPORATION
Entity type:Organization
Organization Name:TRACEY H NGUYEN OD - PROFESSIONAL OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:H
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:602-349-2933
Mailing Address - Street 1:1041 WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:KINGSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:93631-3813
Mailing Address - Country:US
Mailing Address - Phone:559-897-1071
Mailing Address - Fax:
Practice Address - Street 1:1401 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:KINGSBURG
Practice Address - State:CA
Practice Address - Zip Code:93631-1946
Practice Address - Country:US
Practice Address - Phone:559-897-1071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-05
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0697441Medicaid