MEDICARE: EYE CENTER OPTOMETRICS, A PROFESSIONAL CORPORATION

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	COR 1075	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ50558Z	OTHER	CA	BLUE SHIELD PIN
2	ZZZ69113Z	OTHER	CA	BLUE SHIELD PIN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	ZZZ50557Z	OTHER	CA	BLUE SHIELD PIN

General Provider Information

NPI Number	:	1245369024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE CENTER OPTOMETRICS, A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	5959 GREENBACK LN
Second Line	:	SUITE 130
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95621-4700
Country	:	US
Telephone Number	:	916-726-1818
Fax Number	:	916-726-1822

Provider Business Practice Location Address
First Line	:	5959 GREENBACK LN
Second Line	:	SUITE 130
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95621-4700
Country	:	US
Telephone Number	:	916-726-1818
Fax Number	:	916-726-1822

Authorized Official
Title or Position	:	COMMUNICATIONS DIRECTOR
Name	:	LORI L COOPER
Credential	:
Telephone Number	:	916-726-1818

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	03/31/2014

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