MEDICARE: BLACKSTONE OPTOMETRY

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	12032T	CA

General Provider Information

NPI Number	:	1205174828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACKSTONE OPTOMETRY

Provider Business Mailing Address
First Line	:	2109 HILLHURST AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-2003
Country	:	US
Telephone Number	:	323-660-2020
Fax Number	:	323-660-2888

Provider Business Practice Location Address
First Line	:	2109 HILLHURST AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-2003
Country	:	US
Telephone Number	:	323-660-2020
Fax Number	:	323-660-2888

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SIMON CHENG
Credential	:	O.D.
Telephone Number	:	323-660-2020

Provider Enumeration Date	:	01/17/2013
Last Update Date	:	01/17/2013

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Directions to “BLACKSTONE OPTOMETRY ” Practice Location

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