MEDICARE: EYE TREATMENT CENTER, AN INCORPORATED 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	207W00000X	Ophthalmology Physician	G72572	CA

General Provider Information

NPI Number	:	1891026969
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE TREATMENT CENTER, AN INCORPORATED MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	1045 ATLANTIC AVE STE 1007
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90813-3413
Country	:	US
Telephone Number	:	562-436-4558
Fax Number	:	562-437-0079

Provider Business Practice Location Address
First Line	:	1150 E 4TH ST
Second Line	:	LONG BEACH SENIOR CENTER
City	:	LONG BEACH
State	:	CA
Zip	:	90802-1735
Country	:	US
Telephone Number	:	562-570-3500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	IRENE SASAKI
Credential	:	MD
Telephone Number	:	562-436-4558

Provider Enumeration Date	:	01/28/2010
Last Update Date	:	03/02/2010

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