MEDICARE: JOHN C PACK, O.D. AND BEVERLY BIANES, O.D. 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

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
2	1255396461	OTHER	CA	BLUE CROSS OF CALIFORNIA

General Provider Information

NPI Number	:	1255396461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN C PACK, O.D. AND BEVERLY BIANES, O.D. INC

Provider Business Mailing Address
First Line	:	374 E H ST
Second Line	:	SUITE 1708
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-7484
Country	:	US
Telephone Number	:	619-425-7990
Fax Number	:	619-425-7992

Provider Business Practice Location Address
First Line	:	374 E H ST
Second Line	:	SUITE 1708
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-7484
Country	:	US
Telephone Number	:	619-425-7990
Fax Number	:	619-425-7992

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DONNA L FORTE
Credential	:
Telephone Number	:	619-425-7990

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	11/27/2013

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