MEDICARE: PREMIER EYECARE OF EDMOND PLLC

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	152W00000X	Optometrist	2613	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295930410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER EYECARE OF EDMOND PLLC

Provider Business Mailing Address
First Line	:	2841 NW 173RD ST
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73012-6728
Country	:	US
Telephone Number	:	405-513-8150
Fax Number	:	405-513-8153

Provider Business Practice Location Address
First Line	:	2841 NW 173RD STREET
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73003
Country	:	US
Telephone Number	:	405-513-8150
Fax Number	:	405-513-8153

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. AMBER MAYES
Credential	:	O.D.
Telephone Number	:	405-513-8150

Provider Enumeration Date	:	06/18/2007
Last Update Date	:	05/26/2026

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