MEDICARE: MIRA MESA 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
1	152W00000X	Optometrist	9901	CA

General Provider Information

NPI Number	:	1265895221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRA MESA OPTOMETRY, INC

Provider Business Mailing Address
First Line	:	8230 MIRA MESA BLVD STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-2625
Country	:	US
Telephone Number	:	858-566-6670
Fax Number	:	858-566-5152

Provider Business Practice Location Address
First Line	:	8230 MIRA MESA BLVD STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-2625
Country	:	US
Telephone Number	:	858-566-6670
Fax Number	:	858-566-5152

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. ORLANDO GUIANG
Credential	:
Telephone Number	:	858-566-6670

Provider Enumeration Date	:	03/29/2016
Last Update Date	:	03/29/2016

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