MEDICARE: MARINA EYECARE CENTER

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	7001T	CA

General Provider Information

NPI Number	:	1407917701
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARINA EYECARE CENTER

Provider Business Mailing Address
First Line	:	12461 W WASHINGTON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-5511
Country	:	US
Telephone Number	:	310-390-6287
Fax Number	:	310-391-8464

Provider Business Practice Location Address
First Line	:	12461 W WASHINGTON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-5511
Country	:	US
Telephone Number	:	310-390-6287
Fax Number	:	310-391-8464

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DONALD M MATSUMOTO
Credential	:	O.D.
Telephone Number	:	310-390-6287

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	03/01/2018

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