MEDICARE: SAM'S CLUB OPTICAL

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
2	156FX1800X	Optician

General Provider Information

NPI Number	:	1104095801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAM'S CLUB OPTICAL

Provider Business Mailing Address
First Line	:	702 SW 8TH ST.
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716
Country	:	US
Telephone Number	:	479-277-9373
Fax Number	:	479-277-8176

Provider Business Practice Location Address
First Line	:	7100 WEST ARROYO CROSSING PKWY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113
Country	:	US
Telephone Number	:	702-260-7303
Fax Number	:

Authorized Official
Title or Position	:	NPI ASSOCIATE
Name	:	DAVID J SIMMONS
Credential	:
Telephone Number	:	479-277-9373

Provider Enumeration Date	:	02/27/2008
Last Update Date	:	02/27/2008

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Directions to “SAM'S CLUB OPTICAL ” Practice Location

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