MEDICARE: EYE BOUTIQUE 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	7882TPA	CA

General Provider Information

NPI Number	:	1215296637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE BOUTIQUE OPTOMETRY INC

Provider Business Mailing Address
First Line	:	2908 EL CAMINO REAL STE 120
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95051-2944
Country	:	US
Telephone Number	:	408-984-2020
Fax Number	:	408-984-2016

Provider Business Practice Location Address
First Line	:	2908 EL CAMINO REAL STE 120
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95051-2944
Country	:	US
Telephone Number	:	408-984-2020
Fax Number	:	408-984-2016

Authorized Official
Title or Position	:	OWNER
Name	:	SOMI OH
Credential	:
Telephone Number	:	408-984-2020

Provider Enumeration Date	:	05/04/2012
Last Update Date	:	02/21/2023

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