MEDICARE: PROVECTUS FAMILY EYE CARE

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

General Provider Information

NPI Number	:	1538784889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVECTUS FAMILY EYE CARE

Provider Business Mailing Address
First Line	:	2605 BARTON CREEK BLVD
Second Line	:
City	:	THE COLONY
State	:	TX
Zip	:	75056-4357
Country	:	US
Telephone Number	:	469-237-0805
Fax Number	:

Provider Business Practice Location Address
First Line	:	4800 S HULEN ST STE 147
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1415
Country	:	US
Telephone Number	:	817-769-8566
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	JOSEPH KHANG VU
Credential	:	OD
Telephone Number	:	469-237-0805

Provider Enumeration Date	:	06/12/2020
Last Update Date	:	06/12/2020

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