MEDICARE: IAN KAWAMOTO, OD LLC

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	512	NV

General Provider Information

NPI Number	:	1942325634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IAN KAWAMOTO, OD LLC

Provider Business Mailing Address
First Line	:	4825 S RAINBOW BLVD
Second Line	:	STE. 203
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-4914
Country	:	US
Telephone Number	:	702-252-7310
Fax Number	:	702-252-7320

Provider Business Practice Location Address
First Line	:	4825 S RAINBOW BLVD
Second Line	:	STE. 203
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-4914
Country	:	US
Telephone Number	:	702-252-7310
Fax Number	:	702-252-7320

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. IAN KAWAMOTO
Credential	:	O.D.
Telephone Number	:	702-252-7310

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	08/22/2020

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