MEDICARE: MISSION VALLEY FAMILY OPTOMETRY

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

General Provider Information

NPI Number	:	1801440235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSION VALLEY FAMILY OPTOMETRY

Provider Business Mailing Address
First Line	:	1640 CAMINO DEL RIO N STE 200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-1523
Country	:	US
Telephone Number	:	619-299-3113
Fax Number	:	619-299-0766

Provider Business Practice Location Address
First Line	:	1640 CAMINO DEL RIO N STE 200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-1523
Country	:	US
Telephone Number	:	619-299-3113
Fax Number	:	619-299-0766

Authorized Official
Title or Position	:	MANAGING DOCTOR
Name	:	DR. LAHEQA SULJUKI
Credential	:	OD
Telephone Number	:	619-299-3113

Provider Enumeration Date	:	07/24/2019
Last Update Date	:	07/24/2019

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Directions to “MISSION VALLEY FAMILY OPTOMETRY ” Practice Location

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