MEDICARE: MICHAEL T CHISM OPTOMETRY STUDENT

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	390200000X	Student in an Organized Health Care Education/Training Program		CA

General Provider Information

NPI Number	:	1770866840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL T CHISM OPTOMETRY STUDENT

Provider Business Mailing Address
First Line	:	5924 S 1475 W
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84123-5380
Country	:	US
Telephone Number	:	909-631-7188
Fax Number	:

Provider Business Practice Location Address
First Line	:	6344 S 900 E
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84121-2439
Country	:	US
Telephone Number	:	801-892-8222
Fax Number	:

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

Provider Enumeration Date	:	09/24/2011
Last Update Date	:	01/22/2015

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