MEDICARE: MEL GARLAND 1 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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1548818529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEL GARLAND 1 LLC

Provider Business Mailing Address
First Line	:	1784 W MCDERMOTT DR STE 110
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75013-3395
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4280 LAVON DR STE 236B
Second Line	:
City	:	GARLAND
State	:	TX
Zip	:	75040-2971
Country	:	US
Telephone Number	:	469-722-1820
Fax Number	:	561-828-8367

Authorized Official
Title or Position	:	CREDENTIALING SUPERVISOR
Name	:	JACKIE BENNETT
Credential	:
Telephone Number	:	561-433-6009

Provider Enumeration Date	:	09/03/2019
Last Update Date	:	02/19/2021

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Directions to “MEL GARLAND 1 LLC ” Practice Location

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