MEDICARE: PARADIGM VISION CARE MEDICAL ASSOCIATES

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	174400000X	Specialist

General Provider Information

NPI Number	:	1891892071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARADIGM VISION CARE MEDICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	301 N PRAIRIE AVE
Second Line	:	SUITE 601
City	:	INGLEWOOD
State	:	CA
Zip	:	90301-4507
Country	:	US
Telephone Number	:	310-673-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 N PRAIRIE AVE
Second Line	:	SUITE 601
City	:	INGLEWOOD
State	:	CA
Zip	:	90301-4507
Country	:	US
Telephone Number	:	310-673-2020
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WILLIE BENTON BOONE
Credential	:	M.D.
Telephone Number	:	310-673-2020

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/22/2020

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