=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528162690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYECARE SPECIALISTS MEDICAL GROUP, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2006
-----------------------------------------------------
Last Update Date | 11/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5991 E. SPRING ST.
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-938-9945
-----------------------------------------------------
Fax | 562-496-0433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 888 S DISNEYLAND DR SUITE 100
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92802-1847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-604-4621
-----------------------------------------------------
Fax | 714-829-3232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SUPERVISOR
-----------------------------------------------------
Name | FELISA MARISOL GALINDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 626-305-9100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | W14969
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | W14969
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------