Provider Demographics
NPI:1902475825
Name:QUACH, SALENA KIM (OD)
Entity Type:Individual
Prefix:
First Name:SALENA
Middle Name:KIM
Last Name:QUACH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 S DIAMOND BAR BLVD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4122
Mailing Address - Country:US
Mailing Address - Phone:909-861-4999
Mailing Address - Fax:713-743-0963
Practice Address - Street 1:1255 S DIAMOND BAR BLVD
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-4122
Practice Address - Country:US
Practice Address - Phone:909-861-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10358152W00000X
CA34983152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10358OtherTEXAS OPTOMETRY BOARD
TX425425201Medicaid
CA34983OtherCALIFORNIA BOARD OF OPTOMETRY