=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023173044
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARRET BRUCE LOUIE O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2006
-----------------------------------------------------
Last Update Date | 03/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2225 BUCHANAN RD SUITE B
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94509-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-757-6707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2225 BUCHANAN RD SUITE B
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94509-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-757-6707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 10712T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------