MEDICARE: BRUCE E BENEDICT 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	1329-035	WI

General Provider Information

NPI Number	:	1710971841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE E BENEDICT O.D.

Provider Business Mailing Address
First Line	:	23940 GREY FOX LN
Second Line	:
City	:	GRANTSBURG
State	:	WI
Zip	:	54840-8551
Country	:	US
Telephone Number	:	715-463-2459
Fax Number	:

Provider Business Practice Location Address
First Line	:	617 S PINE ST
Second Line	:
City	:	GRANTSBURG
State	:	WI
Zip	:	54840-7935
Country	:	US
Telephone Number	:	715-463-2459
Fax Number	:

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

Provider Enumeration Date	:	09/05/2005
Last Update Date	:	07/08/2007

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