MEDICARE: SKI RUN OPTOMETRY BY DR. LONDON, PC

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	:	1558957589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKI RUN OPTOMETRY BY DR. LONDON, PC

Provider Business Mailing Address
First Line	:	3637 LARCH AVE STE 2
Second Line	:
City	:	S LAKE TAHOE
State	:	CA
Zip	:	96150-8478
Country	:	US
Telephone Number	:	530-544-3403
Fax Number	:	530-544-4032

Provider Business Practice Location Address
First Line	:	3637 LARCH AVE STE 2
Second Line	:
City	:	S LAKE TAHOE
State	:	CA
Zip	:	96150-8478
Country	:	US
Telephone Number	:	530-544-3403
Fax Number	:	530-544-4032

Authorized Official
Title or Position	:	OPTOMETRIST AND OWNER
Name	:	DR. KELLIE LONDON
Credential	:	OD
Telephone Number	:	530-544-3403

Provider Enumeration Date	:	12/14/2020
Last Update Date	:	04/07/2026

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