MEDICARE: DE LA PENA EYE CLINIC, A MEDICAL GROUP, INC

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
2	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1831536481
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DE LA PENA EYE CLINIC, A MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	401 COMMERCE ST STE 600
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37219-2518
Country	:	US
Telephone Number	:	615-345-6900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 N GRAND AVE
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92701-2627
Country	:	US
Telephone Number	:	714-558-1385
Fax Number	:	714-558-7269

Authorized Official
Title or Position	:	MEMBER, BOARD OF MANAGERS
Name	:	MARK KELLY
Credential	:
Telephone Number	:	615-345-6900

Provider Enumeration Date	:	05/22/2013
Last Update Date	:	02/18/2020

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