MEDICARE: MR. HORACE EARL FERGUSON JR. 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

General Provider Information

NPI Number	:	1124386438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HORACE EARL FERGUSON JR. OPTICIAN

Provider Business Mailing Address
First Line	:	4535 DICK POND ROAD
Second Line	:	A
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588
Country	:	US
Telephone Number	:	843-655-2299
Fax Number	:

Provider Business Practice Location Address
First Line	:	4535 DICK POND ROAD
Second Line	:	A
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588
Country	:	US
Telephone Number	:	843-655-2299
Fax Number	:

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

Provider Enumeration Date	:	04/25/2012
Last Update Date	:	04/25/2012

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