MEDICARE: MEL VISION 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

General Provider Information

NPI Number	:	1174114193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEL VISION LLC

Provider Business Mailing Address
First Line	:	2199 GLENMORE LN
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-5611
Country	:	US
Telephone Number	:	561-275-2020
Fax Number	:	561-828-8367

Provider Business Practice Location Address
First Line	:	4700 SE 15TH ST
Second Line	:
City	:	DEL CITY
State	:	OK
Zip	:	73115-3966
Country	:	US
Telephone Number	:	561-275-2020
Fax Number	:	561-828-8367

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	JACKIE BENNETT
Credential	:
Telephone Number	:	505-365-0979

Provider Enumeration Date	:	02/02/2021
Last Update Date	:	02/19/2021

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