=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477005973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DORIS BOUDAIE OPTOMETRIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2016
-----------------------------------------------------
Last Update Date | 11/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8500 BEVERLY BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-6201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-360-3937
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 260 S BEVERLY DR STE 333
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90212-3810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DORIS BOUDAIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-770-9645
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------