MEDICARE: MR. MICKEY LEE DRAKE I 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	156FX1800X	Optician	L-981101	AR
2	156FX1800X	Optician	L-030454	AR

General Provider Information

NPI Number	:	1053643817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICKEY LEE DRAKE I OPTICIAN

Provider Business Mailing Address
First Line	:	111 PONDEROSA LN
Second Line	:	SUITE H
City	:	HOT SPRINGS VILLAGE
State	:	AR
Zip	:	71909-5018
Country	:	US
Telephone Number	:	501-984-5955
Fax Number	:	501-984-5955

Provider Business Practice Location Address
First Line	:	111 PONDEROSA LN
Second Line	:	SUITE H
City	:	HOT SPRINGS VILLAGE
State	:	AR
Zip	:	71909-5018
Country	:	US
Telephone Number	:	501-984-5955
Fax Number	:	501-984-5955

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

Provider Enumeration Date	:	02/04/2010
Last Update Date	:	02/04/2010

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