MEDICARE: BEACH CITIES OPTOMETRY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	COR900	CA

General Provider Information

NPI Number	:	1023082690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACH CITIES OPTOMETRY, INC.

Provider Business Mailing Address
First Line	:	1103 HIGHLAND AVE
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-5310
Country	:	US
Telephone Number	:	310-376-8975
Fax Number	:

Provider Business Practice Location Address
First Line	:	1103 HIGHLAND AVE
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-5310
Country	:	US
Telephone Number	:	310-376-8975
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	ROBERT STAHL
Credential	:	O.D.
Telephone Number	:	310-376-8975

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	10/26/2016

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