MEDICARE: OPTICAL OUTLET, INC

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	749	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0785940002	OTHER	TN	PALMETTO DME

General Provider Information

NPI Number	:	1588820393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTICAL OUTLET, INC

Provider Business Mailing Address
First Line	:	826 MOUNT MORIAH RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38117-5705
Country	:	US
Telephone Number	:	901-683-3232
Fax Number	:	901-683-4463

Provider Business Practice Location Address
First Line	:	826 MOUNT MORIAH RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38117-5705
Country	:	US
Telephone Number	:	901-683-3232
Fax Number	:	901-683-4463

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KENNETH A WEINBERG
Credential	:	O.D.
Telephone Number	:	901-683-3232

Provider Enumeration Date	:	07/31/2008
Last Update Date	:	07/31/2008

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Directions to “OPTICAL OUTLET, INC ” Practice Location

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