MEDICARE: MARINA OPTOMETRY A PROFESSIONAL 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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1255010542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARINA OPTOMETRY A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	249 LOCKFORD
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92602-0957
Country	:	US
Telephone Number	:	630-903-8988
Fax Number	:

Provider Business Practice Location Address
First Line	:	588 WASHINGTON BLVD
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-5421
Country	:	US
Telephone Number	:	310-577-6608
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PAUL KIM
Credential	:	OD
Telephone Number	:	630-903-8988

Provider Enumeration Date	:	07/13/2023
Last Update Date	:	08/18/2023

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