MEDICARE: ELITE EYECARE MEDICAL GROUP A MEDICAL CORPORATION

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	207W00000X	Ophthalmology Physician

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	:	1245548023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE EYECARE MEDICAL GROUP A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	910 E STOWELL RD
Second Line	:
City	:	SANTA MARIA
State	:	CA
Zip	:	93454-7001
Country	:	US
Telephone Number	:	805-925-2637
Fax Number	:	805-347-0033

Provider Business Practice Location Address
First Line	:	1429 S BROADWAY
Second Line	:
City	:	SANTA MARIA
State	:	CA
Zip	:	93454
Country	:	US
Telephone Number	:	805-925-9575
Fax Number	:	805-347-0033

Authorized Official
Title or Position	:	CEO
Name	:	DR. KENNETH R KENDALL
Credential	:	O.D
Telephone Number	:	805-922-2637

Provider Enumeration Date	:	09/15/2010
Last Update Date	:	10/01/2018

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