MEDICARE: DESERT MEDICAL EYE CENTER OPTICAL SHOP

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	5468	NV

General Provider Information

NPI Number	:	1568422335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT MEDICAL EYE CENTER OPTICAL SHOP

Provider Business Mailing Address
First Line	:	4324 S EASTERN AVE
Second Line	:	SUITE A
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6016
Country	:	US
Telephone Number	:	702-734-9585
Fax Number	:	702-734-9518

Provider Business Practice Location Address
First Line	:	4324 S EASTERN AVE
Second Line	:	SUITE A
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6016
Country	:	US
Telephone Number	:	702-734-9585
Fax Number	:	702-734-9518

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	DR. JUDY M CRAYTHORN
Credential	:	M.D.
Telephone Number	:	702-734-9585

Provider Enumeration Date	:	03/24/2006
Last Update Date	:	08/11/2008

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