MEDICARE: MAYFAIR REGENCY 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	332H00000X	Eyewear Supplier	DO9859	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0789680001	OTHER	FL	OPTICAL FILL OUT FORMS 1500 FOR CUSTOMERS

General Provider Information

NPI Number	:	1023279460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAYFAIR REGENCY INC.

Provider Business Mailing Address
First Line	:	9430 ARLINGTON EXPY
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-8231
Country	:	US
Telephone Number	:	904-725-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	9430 ARLINGTON EXPY
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-8231
Country	:	US
Telephone Number	:	904-725-2020
Fax Number	:	904-725-4262

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JONATHAN PAUL LOCKERMAN
Credential	:	OPTICIAN
Telephone Number	:	904-725-2020

Provider Enumeration Date	:	06/18/2008
Last Update Date	:	06/18/2008

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