MEDICARE: VISIONCARE OF CALIFORNIA

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

General Provider Information

NPI Number	:	1235437260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISIONCARE OF CALIFORNIA

Provider Business Mailing Address
First Line	:	9625 BLACK MOUNTAIN RD
Second Line	:	311
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-4564
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5450 THORNWOOD DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95123-1222
Country	:	US
Telephone Number	:	408-281-8220
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NICHOLAS SHASHATI
Credential	:
Telephone Number	:	800-454-4647

Provider Enumeration Date	:	02/28/2011
Last Update Date	:	02/28/2011

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