=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861556177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA MARIE RISCO OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14501 HINDRY AVE
-----------------------------------------------------
City | HAWTHORNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90250-6748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-536-0327
-----------------------------------------------------
Fax | 310-536-0328
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2604 VOORHEES AVE UNIT B
-----------------------------------------------------
City | REDONDO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90278-2619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-536-0327
-----------------------------------------------------
Fax | 310-536-0328
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 12128T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------