MEDICARE: DAWN REVERSPECTIVE EYES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	152WC0802X	Corneal and Contact Management Optometrist
2	152WP0200X	Pediatric Optometrist
3	152WS0006X	Sports Vision Optometrist
4	152WX0102X	Occupational Vision Optometrist
5	152W00000X	Optometrist

General Provider Information

NPI Number	:	1720676349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAWN REVERSPECTIVE EYES LLC

Provider Business Mailing Address
First Line	:	1605 COLORADO BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-1402
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1605 COLORADO BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-1402
Country	:	US
Telephone Number	:	323-739-6092
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPTOMETRIST
Name	:	DR. SEPIDEH OMIDGHAEMI
Credential	:	OD
Telephone Number	:	323-739-6092

Provider Enumeration Date	:	01/08/2021
Last Update Date	:	01/08/2021

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Directions to “DAWN REVERSPECTIVE EYES LLC ” Practice Location

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