MEDICARE: ITALEE OPTOMETRIC CENTER, 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	261Q00000X	Clinic/Center	OPT9019TPA	CA

General Provider Information

NPI Number	:	1326357922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ITALEE OPTOMETRIC CENTER, INC.

Provider Business Mailing Address
First Line	:	978 S VERMONT AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-1611
Country	:	US
Telephone Number	:	213-385-1656
Fax Number	:	213-385-8700

Provider Business Practice Location Address
First Line	:	978 S VERMONT AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-1611
Country	:	US
Telephone Number	:	213-385-1656
Fax Number	:	213-385-8700

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	MR. CHRISTOPHER SONG
Credential	:
Telephone Number	:	213-736-0205

Provider Enumeration Date	:	09/29/2010
Last Update Date	:	09/29/2010

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