MEDICARE: DR. KELLY MUI O.D.

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	12896	CA

General Provider Information

NPI Number	:	1063401719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY MUI O.D.

Provider Business Mailing Address
First Line	:	3435 OCEAN PARK BLVD
Second Line	:	SUITE 107 PMB 88
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-3301
Country	:	US
Telephone Number	:	510-220-1779
Fax Number	:

Provider Business Practice Location Address
First Line	:	11777 SAN VICENTE BLVD
Second Line	:	SUITE 130
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-5011
Country	:	US
Telephone Number	:	310-820-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	07/08/2007

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