MEDICARE: DR. MICHELLE RENEE WICKLINE O.D.

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	913OD	WV

General Provider Information

NPI Number	:	1174521850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE RENEE WICKLINE O.D.

Provider Business Mailing Address
First Line	:	RT 1 BOX 75-4
Second Line	:
City	:	SALEM
State	:	WV
Zip	:	26426
Country	:	US
Telephone Number	:	304-782-1005
Fax Number	:	304-782-3303

Provider Business Practice Location Address
First Line	:	RT 1 BOX 75-4
Second Line	:
City	:	SALEM
State	:	WV
Zip	:	26426
Country	:	US
Telephone Number	:	304-782-1005
Fax Number	:	304-782-3303

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	06/29/2012

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