MEDICARE: AEG 8 TX PROFESSIONAL, PLLC

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	:	1083478531
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AEG 8 TX PROFESSIONAL, PLLC

Provider Business Mailing Address
First Line	:	111 E 4TH ST STE 440
Second Line	:
City	:	ALTON
State	:	IL
Zip	:	62002-6206
Country	:	US
Telephone Number	:	618-462-9818
Fax Number	:	314-741-4947

Provider Business Practice Location Address
First Line	:	6850 N SHILOH RD STE T
Second Line	:
City	:	GARLAND
State	:	TX
Zip	:	75044-2918
Country	:	US
Telephone Number	:	972-414-0444
Fax Number	:	314-741-4947

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	CASEY BENNINGTON
Credential	:
Telephone Number	:	618-462-9818

Provider Enumeration Date	:	02/06/2024
Last Update Date	:	02/06/2024

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