MEDICARE: LASSMAN'S FINE EYEWEAR,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	156FX1800X	Optician	090187	OR

General Provider Information

NPI Number	:	1114066933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LASSMAN'S FINE EYEWEAR,INC.

Provider Business Mailing Address
First Line	:	530 CRATER LAKE AVE
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504-6810
Country	:	US
Telephone Number	:	541-774-3937
Fax Number	:	541-774-1937

Provider Business Practice Location Address
First Line	:	530 CRATER LAKE AVE
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504-6810
Country	:	US
Telephone Number	:	541-774-3937
Fax Number	:	541-774-1937

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MRS. CHRISTINA DIANE LASSMAN
Credential	:	ABOC
Telephone Number	:	541-774-3937

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	04/13/2010

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