MEDICARE: LUC EMMANUEL KANICKY O.D.

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	152WL0500X	Low Vision Rehabilitation Optometrist	OPC 003906	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OPC 003906	OTHER	FL	STATE LICENSE

General Provider Information

NPI Number	:	1043275175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUC EMMANUEL KANICKY O.D.

Provider Business Mailing Address
First Line	:	6911 PISTOL RANGE RD
Second Line	:	SUITE 103B
City	:	TAMPA
State	:	FL
Zip	:	33635-6335
Country	:	US
Telephone Number	:	813-925-3393
Fax Number	:	813-925-3394

Provider Business Practice Location Address
First Line	:	6911 PISTOL RANGE RD
Second Line	:	SUITE 103B
City	:	TAMPA
State	:	FL
Zip	:	33635-6335
Country	:	US
Telephone Number	:	813-925-3393
Fax Number	:	813-925-3394

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	05/06/2010

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