MEDICARE: EYE SOURCE 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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1780711911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE SOURCE LLC

Provider Business Mailing Address
First Line	:	21126 SAINT ANDREWS BLVD
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33433-2404
Country	:	US
Telephone Number	:	561-347-7977
Fax Number	:	561-347-7311

Provider Business Practice Location Address
First Line	:	21126 SAINT ANDREWS BLVD
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33433-2404
Country	:	US
Telephone Number	:	561-347-7977
Fax Number	:	561-347-7311

Authorized Official
Title or Position	:	OWNER PHYSICIAN
Name	:	RONALD SNYDER
Credential	:	OD
Telephone Number	:	561-347-7977

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	01/03/2013

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Directions to “EYE SOURCE LLC ” Practice Location

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