=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356589741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNA M PENNINO OD OPTOMETRIC CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2009
-----------------------------------------------------
Last Update Date | 03/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8511 PERSHING DR
-----------------------------------------------------
City | PLAYA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90293-8101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-577-6401
-----------------------------------------------------
Fax | 310-577-6403
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8511 PERSHING DR
-----------------------------------------------------
City | PLAYA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90293-8101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-577-6401
-----------------------------------------------------
Fax | 310-577-6403
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. ANNA M PENNINO
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 310-577-6401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 9996T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------