MEDICARE: LAKE WORTH PREMIER EYE CARE 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	6990-TG	TX

General Provider Information

NPI Number	:	1356707517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE WORTH PREMIER EYE CARE PLLC

Provider Business Mailing Address
First Line	:	6921 FOSTER DR
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-2818
Country	:	US
Telephone Number	:	817-439-9455
Fax Number	:

Provider Business Practice Location Address
First Line	:	6921 FOSTER DR
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-2818
Country	:	US
Telephone Number	:	817-439-9455
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	JEFFREY CRABTREE
Credential	:	O.D,
Telephone Number	:	817-300-9803

Provider Enumeration Date	:	01/04/2016
Last Update Date	:	01/14/2016

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