MEDICARE: EXCLUSIVE EYEWEAR NO. 2, LLC

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	332H00000X	Eyewear Supplier
2	152W00000X	Optometrist

General Provider Information

NPI Number	:	1073123352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCLUSIVE EYEWEAR NO. 2, LLC

Provider Business Mailing Address
First Line	:	1156 - 1158 FEDERAL HIGHWAY
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062
Country	:	US
Telephone Number	:	561-275-2020
Fax Number	:	561-828-8367

Provider Business Practice Location Address
First Line	:	1156 - 1158 FEDERAL HIGHWAY
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062
Country	:	US
Telephone Number	:	561-275-2020
Fax Number	:	561-828-8367

Authorized Official
Title or Position	:	CREDENTIALING SUPERVISOR
Name	:	JACKIE BENNETT
Credential	:
Telephone Number	:	561-612-4531

Provider Enumeration Date	:	08/03/2020
Last Update Date	:	03/16/2021

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