MEDICARE: SOUTH COAST EYE CARE CENTERS

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	332H00000X	Eyewear Supplier	EAA994358090001EA	CA

General Provider Information

NPI Number	:	1518935725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH COAST EYE CARE CENTERS

Provider Business Mailing Address
First Line	:	23961 CALLE DE LA MAGDALENA
Second Line	:	SUITE 302
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-3616
Country	:	US
Telephone Number	:	949-588-2020
Fax Number	:	949-588-0336

Provider Business Practice Location Address
First Line	:	23961 CALLE DE LA MAGDALENA
Second Line	:	SUITE 302
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-3616
Country	:	US
Telephone Number	:	949-588-2020
Fax Number	:	949-588-0336

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. ANDREW HENRICK
Credential	:	M.D.
Telephone Number	:	949-588-2020

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	04/16/2008

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