MEDICARE: JOANNA M GERVAIS OD LLC

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	332H00000X	Eyewear Supplier
2	152W00000X	Optometrist	3263AT	OR

General Provider Information

NPI Number	:	1144556655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOANNA M GERVAIS OD LLC

Provider Business Mailing Address
First Line	:	1871 2ND ST
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-2121
Country	:	US
Telephone Number	:	541-741-0122
Fax Number	:

Provider Business Practice Location Address
First Line	:	1871 2ND ST
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-2121
Country	:	US
Telephone Number	:	541-741-0122
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST/OWNER
Name	:	DR. JOANNA M GERVAIS
Credential	:	OD
Telephone Number	:	541-777-0245

Provider Enumeration Date	:	10/19/2009
Last Update Date	:	11/16/2009

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