MEDICARE: EVERGREEN EYECARE OPTOMETRY INC.

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	12009T	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

General Provider Information

NPI Number	:	1518136043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN EYECARE OPTOMETRY INC.

Provider Business Mailing Address
First Line	:	3005 SILVER CREEK RD STE 104
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95121-1789
Country	:	US
Telephone Number	:	408-238-4900
Fax Number	:	408-238-4903

Provider Business Practice Location Address
First Line	:	3005 SILVER CREEK RD STE 104
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95121-1789
Country	:	US
Telephone Number	:	408-238-4900
Fax Number	:	408-238-4903

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BANG K. TRAN
Credential	:	O.D.
Telephone Number	:	408-238-4900

Provider Enumeration Date	:	02/28/2008
Last Update Date	:	05/22/2009

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