MEDICARE: OPTOMETRIC PROVIDERS OF RHODE ISLAND, INC

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

General Provider Information

NPI Number	:	1053505263
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTOMETRIC PROVIDERS OF RHODE ISLAND, INC

Provider Business Mailing Address
First Line	:	2921 ERIE BLVD E
Second Line	:	C/O EMPIRE VISION CENTER, INC
City	:	SYRACUSE
State	:	NY
Zip	:	13224-1430
Country	:	US
Telephone Number	:	315-445-7465
Fax Number	:	315-445-7675

Provider Business Practice Location Address
First Line	:	45 NEWPORT AVE STE A
Second Line	:
City	:	RUMFORD
State	:	RI
Zip	:	02916-2070
Country	:	US
Telephone Number	:	401-434-9870
Fax Number	:	401-434-9876

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL R IANNUCCILLI
Credential	:	OD
Telephone Number	:	401-782-2100

Provider Enumeration Date	:	08/30/2007
Last Update Date	:	08/21/2009

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