MEDICARE: PACK OPTICAL

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	:	1154506822
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACK OPTICAL

Provider Business Mailing Address
First Line	:	1217 OAK KNOLL DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76117-5505
Country	:	US
Telephone Number	:	817-831-6141
Fax Number	:

Provider Business Practice Location Address
First Line	:	1217 OAK KNOLL DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76117-5505
Country	:	US
Telephone Number	:	817-831-6141
Fax Number	:

Authorized Official
Title or Position	:	OWNNER
Name	:	EDWIN M PACK
Credential	:	O.D.
Telephone Number	:	817-831-6141

Provider Enumeration Date	:	12/31/2007
Last Update Date	:	02/07/2008

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Directions to “PACK OPTICAL ” Practice Location

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