Provider Demographics
NPI:1053745679
Name:EYEGEN VISION CENTER OPTOMETRY, INC
Entity type:Organization
Organization Name:EYEGEN VISION CENTER OPTOMETRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-841-9888
Mailing Address - Street 1:16835 ALGONQUIN ST
Mailing Address - Street 2:SUITE 383
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3810
Mailing Address - Country:US
Mailing Address - Phone:714-841-9888
Mailing Address - Fax:
Practice Address - Street 1:16845 ALGONQUIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-3810
Practice Address - Country:US
Practice Address - Phone:714-841-9888
Practice Address - Fax:714-841-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-30
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U55767Medicare UPIN