Provider Demographics
NPI:1962869545
Name:OPTOMETRX
Entity type:Organization
Organization Name:OPTOMETRX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:KWAN YANG
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-610-6727
Mailing Address - Street 1:17134B COLIMA ROAD
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745
Mailing Address - Country:US
Mailing Address - Phone:626-610-6727
Mailing Address - Fax:
Practice Address - Street 1:17134B COLIMA ROAD
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745
Practice Address - Country:US
Practice Address - Phone:626-610-6727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA9910T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB 245522Medicare PIN