MEDICARE: MOUNT VERNON EYE CARE

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	5970	OH

General Provider Information

NPI Number	:	1801181425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT VERNON EYE CARE

Provider Business Mailing Address
First Line	:	6899 LAKEBROOK BLVD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43235-2724
Country	:	US
Telephone Number	:	602-206-1580
Fax Number	:

Provider Business Practice Location Address
First Line	:	1558 COSHOCTON AVE
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-5416
Country	:	US
Telephone Number	:	740-392-1456
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	XUAN T. PHAM
Credential	:	O.D.
Telephone Number	:	602-206-1580

Provider Enumeration Date	:	06/10/2011
Last Update Date	:	06/10/2011

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