Basic Information
| Provider Information | |||||||||
| NPI: | 1104836527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YASUNARI | ||||||||
| FirstName: | LOREN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10390 WILSHIRE BLVD APT 1008 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900246420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104538911 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 450 N ROXBURY DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902104232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104538911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 12125T | CA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 12125T | 01 | CA | LICENSE | OTHER | MY0717201 | 01 | CA | DEA REGISTRATION | OTHER |