MEDICARE: LORI ELLEN MARION O.D.

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	09912T	CA

General Provider Information

NPI Number	:	1972575710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI ELLEN MARION O.D.

Provider Business Mailing Address
First Line	:	43064 VIA MORAGA
Second Line	:
City	:	FREMONT
State	:	CA
Zip	:	94539-5748
Country	:	US
Telephone Number	:	510-651-4674
Fax Number	:

Provider Business Practice Location Address
First Line	:	43064 VIA MORAGA
Second Line	:
City	:	FREMONT
State	:	CA
Zip	:	94539-5748
Country	:	US
Telephone Number	:	510-651-4674
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2006
Last Update Date	:	07/08/2007

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