MEDICARE: DR. GLENDA BOTTOMS SECOR OD

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	CA797T	CA

General Provider Information

NPI Number	:	1639252117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENDA BOTTOMS SECOR OD

Provider Business Mailing Address
First Line	:	17742 BEACH BLVD
Second Line	:	# 305
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-6853
Country	:	US
Telephone Number	:	714-596-4488
Fax Number	:	714-596-5522

Provider Business Practice Location Address
First Line	:	17742 BEACH BLVD # 305
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-6853
Country	:	US
Telephone Number	:	714-596-4488
Fax Number	:	714-596-5522

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

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	10/15/2010

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