MEDICARE: OPTOMETRIC SPECIALTIES 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	332H00000X	Eyewear Supplier	COR 889	CA
2	152W00000X	Optometrist	COR 889	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023094570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTOMETRIC SPECIALTIES INC

Provider Business Mailing Address
First Line	:	3750 SANTA ROSALIA DR STE 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-3685
Country	:	US
Telephone Number	:	323-294-7517
Fax Number	:

Provider Business Practice Location Address
First Line	:	3750 SANTA ROSALIA DR STE 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-3685
Country	:	US
Telephone Number	:	323-294-7517
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ERIC E GAYLORD
Credential	:	O.D.
Telephone Number	:	323-294-7517

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	06/16/2018

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Directions to “OPTOMETRIC SPECIALTIES INC ” Practice Location

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