=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912203787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHANNON O. ALTURAS, O.D., A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2011
-----------------------------------------------------
Last Update Date | 08/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3658 S NOGALES ST
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91792-2714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-539-3543
-----------------------------------------------------
Fax | 866-597-7977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3658 S NOGALES ST
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91792-2714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-539-3543
-----------------------------------------------------
Fax | 866-597-7977
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. SHANNON OLARIO ALTURAS
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 626-539-3543
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 12898 T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------