MEDICARE: EAST BAY VISION CENTER OPTOMETRY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	8533T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083743066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST BAY VISION CENTER OPTOMETRY INC

Provider Business Mailing Address
First Line	:	34420 FREMONT BLVD
Second Line	:	STE E
City	:	FREMONT
State	:	CA
Zip	:	94555-3323
Country	:	US
Telephone Number	:	510-796-9600
Fax Number	:	510-796-9691

Provider Business Practice Location Address
First Line	:	34420 FREMONT BLVD
Second Line	:	STE E
City	:	FREMONT
State	:	CA
Zip	:	94555-3323
Country	:	US
Telephone Number	:	510-796-9600
Fax Number	:	510-796-9691

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. EILEEN S LO
Credential	:	O.D.
Telephone Number	:	510-796-9600

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	02/28/2011

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