MEDICARE: PROFESSIONAL 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

General Provider Information

NPI Number	:	1154682466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL OPTICAL

Provider Business Mailing Address
First Line	:	525 N TEJON ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-1109
Country	:	US
Telephone Number	:	719-471-3937
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 N TEJON ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-1109
Country	:	US
Telephone Number	:	719-471-3937
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MS. BARBARA A MCCOLLOUGH
Credential	:	ABOC
Telephone Number	:	719-471-3937

Provider Enumeration Date	:	06/04/2012
Last Update Date	:	06/04/2012

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Directions to “PROFESSIONAL OPTICAL ” Practice Location

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