MEDICARE: DR. BRENT COLEMAN LAIRCEY O.D.

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	002175	GA

General Provider Information

NPI Number	:	1447286976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENT COLEMAN LAIRCEY O.D.

Provider Business Mailing Address
First Line	:	632 COLFAX STATION DR
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-0107
Country	:	US
Telephone Number	:	912-764-5110
Fax Number	:	912-489-7655

Provider Business Practice Location Address
First Line	:	820 US HIGHWAY 80 E
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30461-0800
Country	:	US
Telephone Number	:	912-489-3937
Fax Number	:	912-489-7655

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

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. BRENT COLEMAN LAIRCEY O.D.” Practice Location

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