MEDICARE: DR. LILY MAC O.D.

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 13519	CA

General Provider Information

NPI Number	:	1508022021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LILY MAC O.D.

Provider Business Mailing Address
First Line	:	1450 TARA HILLS DR
Second Line	:	STE D
City	:	PINOLE
State	:	CA
Zip	:	94564-2517
Country	:	US
Telephone Number	:	626-282-2567
Fax Number	:

Provider Business Practice Location Address
First Line	:	1450 TARA HILLS DR
Second Line	:	STE D
City	:	PINOLE
State	:	CA
Zip	:	94564-2517
Country	:	US
Telephone Number	:	626-282-2567
Fax Number	:

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

Provider Enumeration Date	:	08/04/2008
Last Update Date	:	02/16/2016

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Directions to “ DR. LILY MAC O.D.” Practice Location

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