MEDICARE: DR. THERESA M. CERVINSKI O.D.

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	2562ATI	OR
2	152WV0400X	Vision Therapy Optometrist	2562ATI	OR
3	152W00000X	Optometrist	639	NV
4	152W00000X	Optometrist	13242	CA

General Provider Information

NPI Number	:	1336218445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA M. CERVINSKI O.D.

Provider Business Mailing Address
First Line	:	19530 VAN BUREN BLVD
Second Line	:	G8
City	:	RIVERSIDE
State	:	CA
Zip	:	92508-9455
Country	:	US
Telephone Number	:	951-656-0500
Fax Number	:

Provider Business Practice Location Address
First Line	:	19530 VAN BUREN BLVD
Second Line	:	G8
City	:	RIVERSIDE
State	:	CA
Zip	:	92508-9455
Country	:	US
Telephone Number	:	951-656-0500
Fax Number	:

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

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	09/13/2011

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