MEDICARE: MR. TERRY W CLEAVELAND CERTIFIED OPTICIAN

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

General Provider Information

NPI Number	:	1558315754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TERRY W CLEAVELAND CERTIFIED OPTICIAN

Provider Business Mailing Address
First Line	:	3361 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-5103
Country	:	US
Telephone Number	:	719-573-9425
Fax Number	:	719-597-6113

Provider Business Practice Location Address
First Line	:	3361 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-5103
Country	:	US
Telephone Number	:	719-573-9425
Fax Number	:	719-597-6113

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	07/08/2007

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