=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023238953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIEMS ADVANCED LASIK AND EYE CENTERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 E COAST HWY STE 200
-----------------------------------------------------
City | CORONA DEL MAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92625-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-718-2010
-----------------------------------------------------
Fax | 949-718-2011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 E COAST HWY STE 200
-----------------------------------------------------
City | CORONA DEL MAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92625-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-718-2010
-----------------------------------------------------
Fax | 949-718-2011
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPHTHALMIC TECHNICIAN
-----------------------------------------------------
Name | RICKIE ELPUSAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-718-2010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 8933T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------