MEDICARE: DANVILLE OPTOMETRIC 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	152W00000X	Optometrist	OPT 5475 TPA	CA

General Provider Information

NPI Number	:	1710151790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DANVILLE OPTOMETRIC GROUP, INC.

Provider Business Mailing Address
First Line	:	3464 CAMINO TASSAJARA
Second Line	:
City	:	DANVILLE
State	:	CA
Zip	:	94506-4680
Country	:	US
Telephone Number	:	925-736-4911
Fax Number	:	925-736-8272

Provider Business Practice Location Address
First Line	:	3464 CAMINO TASSAJARA
Second Line	:
City	:	DANVILLE
State	:	CA
Zip	:	94506-4680
Country	:	US
Telephone Number	:	925-736-4911
Fax Number	:	925-736-8272

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PETER S VISENDI
Credential	:	O.D.
Telephone Number	:	925-736-4911

Provider Enumeration Date	:	04/21/2008
Last Update Date	:	07/29/2009

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