MEDICARE: LAWRENCE J WAITE

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	TUV4209	NY

General Provider Information

NPI Number	:	1336323195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAWRENCE J WAITE

Provider Business Mailing Address
First Line	:	382 W CHURCH ST
Second Line	:
City	:	ELMIRA
State	:	NY
Zip	:	14901-2621
Country	:	US
Telephone Number	:	607-733-2694
Fax Number	:	607-733-1139

Provider Business Practice Location Address
First Line	:	382 W CHURCH ST
Second Line	:
City	:	ELMIRA
State	:	NY
Zip	:	14901-2621
Country	:	US
Telephone Number	:	607-733-2694
Fax Number	:	607-733-1139

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LAWRENCE JOHN WAITE
Credential	:	OD
Telephone Number	:	607-733-2694

Provider Enumeration Date	:	12/28/2007
Last Update Date	:	04/28/2008

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