Healthcare Provider Details

I. General information

NPI: 1295834299
Provider Name (Legal Business Name): PENELOPE SHOLES SUTER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 CALIFORNIA AVE STE 210
BAKERSFIELD CA
93309-1642
US

IV. Provider business mailing address

5300 CALIFORNIA AVE STE 210
BAKERSFIELD CA
93309-1642
US

V. Phone/Fax

Practice location:
  • Phone: 661-869-2010
  • Fax: 661-869-2708
Mailing address:
  • Phone: 661-869-2010
  • Fax: 661-869-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number08128T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number08128T
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number08128T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: