MEDICARE: GREAT EYES 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	11765T	CA

General Provider Information

NPI Number	:	1811172190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT EYES OPTOMETRY, INC

Provider Business Mailing Address
First Line	:	625 LAS DUNAS ST
Second Line	:
City	:	IMPERIAL
State	:	CA
Zip	:	92251-8000
Country	:	US
Telephone Number	:	714-305-7874
Fax Number	:

Provider Business Practice Location Address
First Line	:	343 S BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90013-1207
Country	:	US
Telephone Number	:	213-626-9978
Fax Number	:	213-628-0500

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JADE NGOC MY DAVIS
Credential	:	O.D.
Telephone Number	:	213-626-9978

Provider Enumeration Date	:	01/04/2008
Last Update Date	:	02/20/2018

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Directions to “GREAT EYES OPTOMETRY, INC ” Practice Location

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