MEDICARE: OPTIC GALLERY

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	302R00000X	Health Maintenance Organization	328	NV

General Provider Information

NPI Number	:	1740209691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIC GALLERY

Provider Business Mailing Address
First Line	:	2146 ORCHARD MIST ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89135-1562
Country	:	US
Telephone Number	:	702-869-4588
Fax Number	:

Provider Business Practice Location Address
First Line	:	1930 VILLAGE CENTER CIR STE 10
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6238
Country	:	US
Telephone Number	:	702-240-2121
Fax Number	:	702-240-5858

Authorized Official
Title or Position	:	PARTNER
Name	:	JENNIFER C MALLINGER
Credential	:	O.D.
Telephone Number	:	702-240-2121

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	08/22/2020

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Directions to “OPTIC GALLERY ” Practice Location

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