MEDICARE: OPTOMETRY ASSOCIATES OF WICHITA FALLS

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	5411T	TX

General Provider Information

NPI Number	:	1710327739
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTOMETRY ASSOCIATES OF WICHITA FALLS

Provider Business Mailing Address
First Line	:	3111 MIDWESTERN PKWY STE 256B
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308-2826
Country	:	US
Telephone Number	:	940-691-1920
Fax Number	:

Provider Business Practice Location Address
First Line	:	3111 MIDWESTERN PKWY STE 256B
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308-2826
Country	:	US
Telephone Number	:	940-691-1920
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. NICOLE MARIE KISH
Credential	:	O.D.
Telephone Number	:	940-691-1920

Provider Enumeration Date	:	07/05/2013
Last Update Date	:	07/05/2013

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