MEDICARE: THE LASIK VISION INSTITUTE, 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	261QS0132X	Ophthalmologic Surgery Clinic/Center

General Provider Information

NPI Number	:	1174881486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE LASIK VISION INSTITUTE, LLC

Provider Business Mailing Address
First Line	:	2000 PALM BEACH LAKES BLVD
Second Line	:	SUITE 800
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-6503
Country	:	US
Telephone Number	:	561-965-9110
Fax Number	:	706-243-4627

Provider Business Practice Location Address
First Line	:	5210 BELFORT RD
Second Line	:	SUITE 110
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6024
Country	:	US
Telephone Number	:	561-965-9110
Fax Number	:	706-243-4627

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BEN COOK
Credential	:
Telephone Number	:	56919659110

Provider Enumeration Date	:	04/25/2012
Last Update Date	:	04/25/2012

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