MEDICARE: CHELSEY BREANNE NOLASCO 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	15180	CA
2	152W00000X	Optometrist	2874	CO

General Provider Information

NPI Number	:	1710120415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHELSEY BREANNE NOLASCO O.D.

Provider Business Mailing Address
First Line	:	6110 MARTINEZ ST
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913-2048
Country	:	US
Telephone Number	:	719-368-2446
Fax Number	:	719-576-9332

Provider Business Practice Location Address
First Line	:	6110 MARTINEZ ST
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913-2048
Country	:	US
Telephone Number	:	719-368-2446
Fax Number	:	719-576-9332

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

Provider Enumeration Date	:	04/09/2009
Last Update Date	:	11/03/2017

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