MEDICARE: MARK MONROE LAVA OPTICIAN

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	156FX1800X	Optician	3926	NY

General Provider Information

NPI Number	:	1275622490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK MONROE LAVA OPTICIAN

Provider Business Mailing Address
First Line	:	2900 OCEAN AVE
Second Line	:	APT. 2D
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3270
Country	:	US
Telephone Number	:	718-743-8467
Fax Number	:

Provider Business Practice Location Address
First Line	:	8949 BAY PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-6437
Country	:	US
Telephone Number	:	718-372-1212
Fax Number	:

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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