MEDICARE: PBW OPTOMETRY PC

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	332H00000X	Eyewear Supplier	1060	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7547290001	OTHER		MEDICARE NSC

General Provider Information

NPI Number	:	1871048405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PBW OPTOMETRY PC

Provider Business Mailing Address
First Line	:	1923 MCCULLOCH BLVD #102
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6722
Country	:	US
Telephone Number	:	928-854-3555
Fax Number	:	928-854-4544

Provider Business Practice Location Address
First Line	:	1923 MCCULLOCH BLVD #102
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6722
Country	:	US
Telephone Number	:	928-854-3555
Fax Number	:	928-854-4544

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	DOONE BURGENER
Credential	:
Telephone Number	:	928-505-5843

Provider Enumeration Date	:	08/24/2016
Last Update Date	:	08/09/2017

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Directions to “PBW OPTOMETRY PC ” Practice Location

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