MEDICARE: MR. RICKEY EARL GOERGES OPTICIAN

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	156FX1700X	Ocularist

General Provider Information

NPI Number	:	1942461629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICKEY EARL GOERGES OPTICIAN

Provider Business Mailing Address
First Line	:	7826 LOUIS PASTEUR DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3474
Country	:	US
Telephone Number	:	210-494-4009
Fax Number	:	210-494-9838

Provider Business Practice Location Address
First Line	:	7826 LOUIS PASTEUR DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3474
Country	:	US
Telephone Number	:	210-494-4009
Fax Number	:	210-494-9838

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

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	06/24/2008

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