MEDICARE: MS. DALE A KLAUSS LDO

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	156FX1800X	Optician	LDO000702	GA

General Provider Information

NPI Number	:	1477185205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DALE A KLAUSS LDO

Provider Business Mailing Address
First Line	:	294 KENWOOD RD STE A
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-3451
Country	:	US
Telephone Number	:	770-815-9254
Fax Number	:

Provider Business Practice Location Address
First Line	:	294 KENWOOD RD STE A
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-3451
Country	:	US
Telephone Number	:	770-815-9254
Fax Number	:

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

Provider Enumeration Date	:	02/10/2020
Last Update Date	:	02/10/2020

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