MEDICARE: EILLEN CAROLINA SOSA SLD

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	156FX1800X	Optician	D7662	CA

General Provider Information

NPI Number	:	1336492685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EILLEN CAROLINA SOSA SLD

Provider Business Mailing Address
First Line	:	1940 FRUITVALE AVE
Second Line	:	SUITE 6
City	:	OAKLAND
State	:	CA
Zip	:	94601-2413
Country	:	US
Telephone Number	:	510-731-6976
Fax Number	:	510-698-8744

Provider Business Practice Location Address
First Line	:	1940 FRUITVALE AVE
Second Line	:	SUITE 6
City	:	OAKLAND
State	:	CA
Zip	:	94601-2413
Country	:	US
Telephone Number	:	510-731-6976
Fax Number	:	510-698-8744

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

Provider Enumeration Date	:	10/24/2012
Last Update Date	:	10/24/2012

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Directions to “ EILLEN CAROLINA SOSA SLD” Practice Location

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