MEDICARE: LA MESA VISION CARE CENTER OPTOMETRY

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	OPT 7490 TPA	CA

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396931176
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA MESA VISION CARE CENTER OPTOMETRY

Provider Business Mailing Address
First Line	:	8007 LA MESA BLVD
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91941-6434
Country	:	US
Telephone Number	:	619-466-5665
Fax Number	:	619-466-5688

Provider Business Practice Location Address
First Line	:	8007 LA MESA BLVD
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91941-6434
Country	:	US
Telephone Number	:	619-466-5665
Fax Number	:	619-466-5688

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THOMAS M HIXSON
Credential	:	O.D.
Telephone Number	:	619-466-5665

Provider Enumeration Date	:	09/14/2007
Last Update Date	:	01/02/2009

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Directions to “LA MESA VISION CARE CENTER OPTOMETRY ” Practice Location

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