MEDICARE: FAMILY VISION CARE OF WAVERLY INC

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	3556/T794	OH

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	:	1306035142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY VISION CARE OF WAVERLY INC

Provider Business Mailing Address
First Line	:	414 W EMMITT AVE
Second Line	:
City	:	WAVERLY
State	:	OH
Zip	:	45690-1008
Country	:	US
Telephone Number	:	740-947-8191
Fax Number	:	740-947-5554

Provider Business Practice Location Address
First Line	:	414 W EMMITT AVE
Second Line	:
City	:	WAVERLY
State	:	OH
Zip	:	45690-1008
Country	:	US
Telephone Number	:	740-947-8191
Fax Number	:	740-947-5554

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GREG G MONTAVON
Credential	:	O.D
Telephone Number	:	740-947-8191

Provider Enumeration Date	:	10/17/2007
Last Update Date	:	02/27/2008

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