MEDICARE: DENISE DILTS-WALDROP

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	156FX1800X	Optician	SL5482	CA

General Provider Information

NPI Number	:	1851812267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE DILTS-WALDROP

Provider Business Mailing Address
First Line	:	4626 SHASTA DAM BLVD
Second Line	:
City	:	SHASTA LAKE
State	:	CA
Zip	:	96019-9414
Country	:	US
Telephone Number	:	530-275-0866
Fax Number	:	530-275-8596

Provider Business Practice Location Address
First Line	:	4626 SHASTA DAM BLVD
Second Line	:
City	:	SHASTA LAKE
State	:	CA
Zip	:	96019-9414
Country	:	US
Telephone Number	:	530-275-0866
Fax Number	:	530-275-8596

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

Provider Enumeration Date	:	07/06/2017
Last Update Date	:	07/21/2022

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