MEDICARE: COLIMA OPTOMETRY 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	152W00000X	Optometrist	13661	CA

General Provider Information

NPI Number	:	1366781650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLIMA OPTOMETRY INC

Provider Business Mailing Address
First Line	:	208 N LINCOLN AVE
Second Line	:	APT. 109
City	:	MONTEREY PARK
State	:	CA
Zip	:	91755-1719
Country	:	US
Telephone Number	:	917-723-6462
Fax Number	:	951-652-0050

Provider Business Practice Location Address
First Line	:	1758 SIERRA LEONE AVE
Second Line	:	SUITE A
City	:	ROWLAND HGHTS
State	:	CA
Zip	:	91748-5837
Country	:	US
Telephone Number	:	626-839-2938
Fax Number	:	951-652-0050

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STEVE PENN
Credential	:	O.D.
Telephone Number	:	951-652-8738

Provider Enumeration Date	:	02/06/2013
Last Update Date	:	02/06/2013

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