MEDICARE: CERVANTES OPTOMETRIC CORPORATION

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	12923	CA

General Provider Information

NPI Number	:	1750536207
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CERVANTES OPTOMETRIC CORPORATION

Provider Business Mailing Address
First Line	:	1662 MAIN ST STE B
Second Line	:
City	:	RAMONA
State	:	CA
Zip	:	92065-5231
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1662 MAIN ST STE B
Second Line	:
City	:	RAMONA
State	:	CA
Zip	:	92065-5231
Country	:	US
Telephone Number	:	760-788-3622
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SUSAN TRUONG CERVANTES
Credential	:	O.D.
Telephone Number	:	760-788-3622

Provider Enumeration Date	:	11/25/2008
Last Update Date	:	11/25/2008

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Directions to “CERVANTES OPTOMETRIC CORPORATION ” Practice Location

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