MEDICARE: GLENDALE 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	12850T	CA

General Provider Information

NPI Number	:	1417224304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENDALE OPTOMETRY

Provider Business Mailing Address
First Line	:	232 S BRAND BLVD
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-1310
Country	:	US
Telephone Number	:	818-937-9102
Fax Number	:

Provider Business Practice Location Address
First Line	:	232 S BRAND BLVD
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-1310
Country	:	US
Telephone Number	:	818-937-9102
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPTOMETRIST
Name	:	DR. ALLISON H PARK
Credential	:	O.D.
Telephone Number	:	818-937-9102

Provider Enumeration Date	:	11/21/2011
Last Update Date	:	11/21/2011

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