Provider Demographics
NPI:1437992864
Name:JESSIA T LY OD INC
Entity type:Organization
Organization Name:JESSIA T LY OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:T
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:323-719-1500
Mailing Address - Street 1:411 E DUARTE RD APT 4
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-3973
Mailing Address - Country:US
Mailing Address - Phone:323-719-1500
Mailing Address - Fax:
Practice Address - Street 1:618 W HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3206
Practice Address - Country:US
Practice Address - Phone:626-303-1966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty