MEDICARE: FIFTH AVENUE EYEWEAR

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

General Provider Information

NPI Number	:	1023140860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIFTH AVENUE EYEWEAR

Provider Business Mailing Address
First Line	:	1223 5TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4304
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	:	76104-4304
Country	:	US
Telephone Number	:	817-870-1291
Fax Number	:	817-870-4928

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. JANICE KAY FAULKNER
Credential	:
Telephone Number	:	817-870-1291

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	08/22/2020

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