MEDICARE: MISS MARLENE R SAN NICOLAS O.D.

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	OL027	GU

General Provider Information

NPI Number	:	1154381515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARLENE R SAN NICOLAS O.D.

Provider Business Mailing Address
First Line	:	PO BOX 6578
Second Line	:
City	:	TAMUNING
State	:	GU
Zip	:	96931-6578
Country	:	US
Telephone Number	:	671-648-3350
Fax Number	:	671-647-3537

Provider Business Practice Location Address
First Line	:	415 CHALAN SAN ANTONIO
Second Line	:	SUITE 111-113
City	:	TAMUNING
State	:	GU
Zip	:	96913-3620
Country	:	US
Telephone Number	:	671-648-3350
Fax Number	:	671-647-3546

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	02/27/2013

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