MEDICARE: MEL OPTICAL LLC

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
2	152W00000X	Optometrist

General Provider Information

NPI Number	:	1679103048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEL OPTICAL LLC

Provider Business Mailing Address
First Line	:	1943 PLEASANT HILL RD
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-4625
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1943 PLEASANT HILL RD
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-4625
Country	:	US
Telephone Number	:	561-275-2020
Fax Number	:	561-828-8367

Authorized Official
Title or Position	:	CREDENTIALING SUPERVISOR
Name	:	JACKIE BENNETT
Credential	:
Telephone Number	:	561-433-6009

Provider Enumeration Date	:	01/24/2020
Last Update Date	:	02/18/2021

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Directions to “MEL OPTICAL LLC ” Practice Location

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