MEDICARE: GLENDALE OPTOMETRIC CENTER

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	13022	CA

General Provider Information

NPI Number	:	1801093653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENDALE OPTOMETRIC CENTER

Provider Business Mailing Address
First Line	:	308 E BROADWAY
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-1011
Country	:	US
Telephone Number	:	818-243-1300
Fax Number	:

Provider Business Practice Location Address
First Line	:	308 E BROADWAY
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-1011
Country	:	US
Telephone Number	:	818-243-1300
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. STACEY TAWNIE GIN
Credential	:	O.D.
Telephone Number	:	818-243-1300

Provider Enumeration Date	:	06/27/2007
Last Update Date	:	04/09/2008

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