=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841526852
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE EYE CARE OPTOMETRY GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2009
-----------------------------------------------------
Last Update Date | 03/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20568 STEVENS CREEK BLVD
-----------------------------------------------------
City | CUPERTINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95014-2130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-777-9000
-----------------------------------------------------
Fax | 408-777-9009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20568 STEVENS CREEK BLVD
-----------------------------------------------------
City | CUPERTINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95014-2130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-777-9000
-----------------------------------------------------
Fax | 408-777-9009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DERRICK T. KOO
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 408-777-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 13260T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------