MEDICARE: EYE MAX OPTOMETRY WILSHIRE, 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	8482T	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	:	1043317068
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE MAX OPTOMETRY WILSHIRE, INC

Provider Business Mailing Address
First Line	:	3359 WILSHIRE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-1803
Country	:	US
Telephone Number	:	213-382-2777
Fax Number	:	213-382-6777

Provider Business Practice Location Address
First Line	:	3359 WILSHIRE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-1803
Country	:	US
Telephone Number	:	213-382-2777
Fax Number	:	213-382-6777

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ERIN SUK-KYUNG HAN
Credential	:	O.D.
Telephone Number	:	213-382-2777

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/10/2008

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