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NPI Code Detail

MEDICARE: SOUTH GATE OPTOMETRY INC

MEDICARE: SOUTH GATE 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
1152W00000XOptometrist9996TCA

Other Identifiers

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

General Provider Information

NPI Number : 1154514370
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTH GATE OPTOMETRY INC
Provider Business Mailing Address
First Line : 3329 TWEEDY BLVD
Second Line :
City : SOUTH GATE
State : CA
Zip : 90280-4324
Country : US
Telephone Number : 323-566-6183
Fax Number :
Provider Business Practice Location Address
First Line : 3329 TWEEDY BLVD
Second Line :
City : SOUTH GATE
State : CA
Zip : 90280-4324
Country : US
Telephone Number : 323-566-6183
Fax Number :
Authorized Official
Title or Position : OWNER
Name : DR. ANNA M PENNINO
Credential : O.D.
Telephone Number : 323-566-6183
Provider Enumeration Date : 08/21/2007
Last Update Date : 02/19/2009

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Directions to “SOUTH GATE OPTOMETRY INC ” Practice Location

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