MEDICARE: DR. BEVERLY BIANES PACK OD

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	9841T	CA

General Provider Information

NPI Number	:	1285692756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BEVERLY BIANES PACK OD

Provider Business Mailing Address
First Line	:	374 EAST H ST
Second Line	:	STE 1708
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-7484
Country	:	US
Telephone Number	:	619-425-7990
Fax Number	:	619-425-7992

Provider Business Practice Location Address
First Line	:	374 EAST H ST
Second Line	:	STE 1708
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-7484
Country	:	US
Telephone Number	:	619-425-7990
Fax Number	:	619-425-7992

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	06/18/2008

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