MEDICARE: EYE SITE SACRAMENTO MEDICAL GROUP, 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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1578866893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE SITE SACRAMENTO MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	4925 J ST
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95819-3828
Country	:	US
Telephone Number	:	916-452-8105
Fax Number	:	916-452-4659

Provider Business Practice Location Address
First Line	:	4925 J ST
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95819-3828
Country	:	US
Telephone Number	:	916-452-8105
Fax Number	:	916-452-4659

Authorized Official
Title or Position	:	MANAGER
Name	:	MS. SUSAN M VAN DUYN
Credential	:
Telephone Number	:	916-452-8105

Provider Enumeration Date	:	12/08/2010
Last Update Date	:	12/08/2010

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