MEDICARE: GRIFFIN OPTOMETRIC GROUP

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	:	1497854384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRIFFIN OPTOMETRIC GROUP

Provider Business Mailing Address
First Line	:	30030 TOWN CENTER DR
Second Line	:
City	:	LAGUNA NIGUEL
State	:	CA
Zip	:	92677-2096
Country	:	US
Telephone Number	:	949-495-3031
Fax Number	:

Provider Business Practice Location Address
First Line	:	140 AVENIDA DEL MAR
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4016
Country	:	US
Telephone Number	:	949-492-1853
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TED POWERS GRIFFIN JR.
Credential	:	OD
Telephone Number	:	949-495-3031

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/02/2012

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