=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164728036
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLLYWOOD VISION CENTER OPTOMETRY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2011
-----------------------------------------------------
Last Update Date | 06/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 CARRILLO DR STE. 105
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-954-5800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 955 CARRILLO DR STE. 105
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-954-5800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. ELISE BRISCO
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 323-954-5800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 8994
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------