MEDICARE: FORT SMITH CATARACT & LASER CENTER 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	261QS0132X	Ophthalmologic Surgery Clinic/Center	AR3967	AR

General Provider Information

NPI Number	:	1124150875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT SMITH CATARACT & LASER CENTER LLC

Provider Business Mailing Address
First Line	:	9001 JENNY LIND RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-8629
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9001 JENNY LIND RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-8629
Country	:	US
Telephone Number	:	479-649-7018
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GARY L BODIFORD
Credential	:	M.D.
Telephone Number	:	479-649-7018

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	04/01/2013

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