MEDICARE: MARK R CHRISTENSEN, O.D., INC., A PROFESSIONAL OPTOMETRIC CORPORATION

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 7874 TPA	CA

General Provider Information

NPI Number	:	1881885309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK R CHRISTENSEN, O.D., INC., A PROFESSIONAL OPTOMETRIC CORPORATION

Provider Business Mailing Address
First Line	:	1710 PENNSYLVANIA AVE STE B
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-3549
Country	:	US
Telephone Number	:	707-425-2187
Fax Number	:	707-434-8130

Provider Business Practice Location Address
First Line	:	1710 PENNSYLVANIA AVE STE B
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-3549
Country	:	US
Telephone Number	:	707-425-2187
Fax Number	:	707-434-8130

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK R CHRISTENSEN
Credential	:	O.D.
Telephone Number	:	707-425-2187

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	05/24/2010

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