MEDICARE: COLLEEN ANNALINA TEJCHMA OD

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	OPT-002492	AZ
2	390200000X	Student in an Organized Health Care Education/Training Program
3	152W00000X	Optometrist	3100	OK

General Provider Information

NPI Number	:	1811518004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN ANNALINA TEJCHMA OD

Provider Business Mailing Address
First Line	:	383 LAKE HAVASU AVE S
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-9368
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	383 LAKE HAVASU AVE S
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-9368
Country	:	US
Telephone Number	:	928-680-1144
Fax Number	:	928-680-8639

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

Provider Enumeration Date	:	04/29/2020
Last Update Date	:	12/01/2022

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