MEDICARE: MRS. STACI PEREA MCMULLEN 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	2151	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386639615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACI PEREA MCMULLEN OD

Provider Business Mailing Address
First Line	:	6071 E WOODMEN RD
Second Line	:	SUITE 205
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-2607
Country	:	US
Telephone Number	:	719-380-6808
Fax Number	:	719-380-5656

Provider Business Practice Location Address
First Line	:	6071 E WOODMEN RD
Second Line	:	SUITE 205
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-2607
Country	:	US
Telephone Number	:	719-380-6808
Fax Number	:	719-380-5656

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

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	07/11/2011

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