MEDICARE: MRS. JANICE KAY FAULKNER OPTICIAN OWNER

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	156FX1800X	Optician	DR3962	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013050319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JANICE KAY FAULKNER OPTICIAN OWNER

Provider Business Mailing Address
First Line	:	1223 5TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104
Country	:	US
Telephone Number	:	817-870-1291
Fax Number	:	817-870-4928

Provider Business Practice Location Address
First Line	:	1223 5TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104
Country	:	US
Telephone Number	:	817-870-1291
Fax Number	:	817-870-4928

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/01/2008

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