MEDICARE: LUIS G. PEREZ-RIVERA OD OPTOMETRIC CORPORATION

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

General Provider Information

NPI Number	:	1467012740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUIS G. PEREZ-RIVERA OD OPTOMETRIC CORPORATION

Provider Business Mailing Address
First Line	:	11134 RANCHO CARMEL DR STE 102
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-4671
Country	:	US
Telephone Number	:	858-673-1084
Fax Number	:	858-673-1867

Provider Business Practice Location Address
First Line	:	11134 RANCHO CARMEL DR STE 102
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-4671
Country	:	US
Telephone Number	:	858-673-1084
Fax Number	:	858-673-1867

Authorized Official
Title or Position	:	OPTOMETRIST/OWNER
Name	:	LUIS G PEREZ-RIVERA
Credential	:	OD
Telephone Number	:	858-673-1084

Provider Enumeration Date	:	06/18/2019
Last Update Date	:	06/18/2019

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