MEDICARE: OPTICAL SHOP OF PALATKA 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	DO889	FL

General Provider Information

NPI Number	:	1669650255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTICAL SHOP OF PALATKA INC

Provider Business Mailing Address
First Line	:	3710 SAINT JOHNS AVE
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-4026
Country	:	US
Telephone Number	:	386-328-2020
Fax Number	:	386-328-6428

Provider Business Practice Location Address
First Line	:	3710 SAINT JOHNS AVE
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-4026
Country	:	US
Telephone Number	:	386-328-2020
Fax Number	:	386-328-6428

Authorized Official
Title or Position	:	OWNER
Name	:	MR. LAWRENCE ALAN CARROLL
Credential	:	OPTICIAN
Telephone Number	:	386-328-2020

Provider Enumeration Date	:	02/05/2008
Last Update Date	:	02/06/2008

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Directions to “OPTICAL SHOP OF PALATKA INC ” Practice Location

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