MEDICARE: DR. LEONARD R. PACK O.D.

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	3719T	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	88047	OTHER	TX	OPTICARE PROVIDER I.D.

General Provider Information

NPI Number	:	1568573574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEONARD R. PACK O.D.

Provider Business Mailing Address
First Line	:	1217 OAK KNOLL DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76117-5505
Country	:	US
Telephone Number	:	817-831-6141
Fax Number	:	682-647-3909

Provider Business Practice Location Address
First Line	:	1217 OAK KNOLL DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76117-5505
Country	:	US
Telephone Number	:	817-831-6141
Fax Number	:	682-647-3909

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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