MEDICARE: JESSICA MERCADO ARCHAMBAULT 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	14819	CA

General Provider Information

NPI Number	:	1780008508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MERCADO ARCHAMBAULT O.D.

Provider Business Mailing Address
First Line	:	12759 FOOTHILL BLVD
Second Line	:	SUITE D
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-9336
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12759 FOOTHILL BLVD STE D
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-9336
Country	:	US
Telephone Number	:	909-899-0026
Fax Number	:

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

Provider Enumeration Date	:	02/13/2014
Last Update Date	:	09/04/2014

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