MEDICARE: DR C 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	7149T	CA

General Provider Information

NPI Number	:	1265570030
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR C OPTOMETRY

Provider Business Mailing Address
First Line	:	10940 SANTA MONICA BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-4539
Country	:	US
Telephone Number	:	310-966-5030
Fax Number	:	310-966-9369

Provider Business Practice Location Address
First Line	:	10940 SANTA MONICA BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-4539
Country	:	US
Telephone Number	:	310-966-5030
Fax Number	:	310-966-9369

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LYNETTE MARIE CACCIOTTI
Credential	:	O.D.
Telephone Number	:	310-966-5030

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	09/05/2012

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