MEDICARE: MR. GUS SINGLETON JR. LICENSED 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	1101004032	VA

General Provider Information

NPI Number	:	1083088082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GUS SINGLETON JR. LICENSED OPTICIAN

Provider Business Mailing Address
First Line	:	205 CRANE CIR
Second Line	:	APT M
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23608-5122
Country	:	US
Telephone Number	:	757-746-5983
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 RESEARCH DR
Second Line	:	SUITE 115
City	:	HAMPTON
State	:	VA
Zip	:	23666-1787
Country	:	US
Telephone Number	:	757-746-5983
Fax Number	:

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

Provider Enumeration Date	:	11/14/2015
Last Update Date	:	11/14/2015

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