MEDICARE: TILLMAN OPTOMETRY LLC

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
2	332H00000X	Eyewear Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	130004329	OTHER	WI	WEA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538142989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TILLMAN OPTOMETRY LLC

Provider Business Mailing Address
First Line	:	2304 S MAIN ST
Second Line	:	TILLMAN OPTOMETRY
City	:	RICE LAKE
State	:	WI
Zip	:	54868-2900
Country	:	US
Telephone Number	:	715-736-1700
Fax Number	:

Provider Business Practice Location Address
First Line	:	2304 S MAIN ST
Second Line	:
City	:	RICE LAKE
State	:	WI
Zip	:	54868-2900
Country	:	US
Telephone Number	:	715-736-1700
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT E TILLMAN
Credential	:	OD
Telephone Number	:	715-736-1700

Provider Enumeration Date	:	11/21/2005
Last Update Date	:	02/20/2012

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Directions to “TILLMAN OPTOMETRY LLC ” Practice Location

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