MEDICARE: HOUSTON PIERCE 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	332B00000X	Durable Medical Equipment & Medical Supplies		IN

General Provider Information

NPI Number	:	1174786511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSTON PIERCE OPTICAL

Provider Business Mailing Address
First Line	:	6049 STELLHORN RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-5357
Country	:	US
Telephone Number	:	260-485-1631
Fax Number	:	260-485-1632

Provider Business Practice Location Address
First Line	:	6049 STELLHORN RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-5357
Country	:	US
Telephone Number	:	260-485-1631
Fax Number	:	260-485-1632

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LISA M GOFF
Credential	:	ABOC
Telephone Number	:	260-485-1631

Provider Enumeration Date	:	07/07/2008
Last Update Date	:	12/09/2008

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Directions to “HOUSTON PIERCE OPTICAL ” Practice Location

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