MEDICARE: KENSINGTON 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	5955	CA
2	152W00000X	Optometrist	9134	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1619911047	OTHER	CA	NPI (INDIVIDUAL)

General Provider Information

NPI Number	:	1801825591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENSINGTON OPTOMETRY INC

Provider Business Mailing Address
First Line	:	396 COLUSA AVE
Second Line	:
City	:	KENSINGTON
State	:	CA
Zip	:	94707-1209
Country	:	US
Telephone Number	:	510-527-1714
Fax Number	:	510-527-1715

Provider Business Practice Location Address
First Line	:	396 COLUSA AVE
Second Line	:
City	:	KENSINGTON
State	:	CA
Zip	:	94707-1209
Country	:	US
Telephone Number	:	510-527-1714
Fax Number	:	510-527-1715

Authorized Official
Title or Position	:	PRESIDENT, OWNER, OPTOMETRIST
Name	:	DR. RUSSELL NORMAN COTTERAL
Credential	:	OD
Telephone Number	:	510-527-1714

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	10/21/2016

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Directions to “KENSINGTON OPTOMETRY INC ” Practice Location

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