MEDICARE: LILIAN V. WALTER 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	1101002209	VA

General Provider Information

NPI Number	:	1144318841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILIAN V. WALTER LICENSED OPTICIAN

Provider Business Mailing Address
First Line	:	5445 QUAINT DR
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-4591
Country	:	US
Telephone Number	:	703-583-9611
Fax Number	:	703-580-6945

Provider Business Practice Location Address
First Line	:	5073 WATERWAY DR
Second Line	:
City	:	DUMFRIES
State	:	VA
Zip	:	22025-1259
Country	:	US
Telephone Number	:	703-580-7274
Fax Number	:	703-580-6945

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	07/08/2007

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