MEDICARE: ST GEORGE OD 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	152W00000X	Optometrist	OPC4985	FL

General Provider Information

NPI Number	:	1174912794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST GEORGE OD LLC

Provider Business Mailing Address
First Line	:	5058 GREENWICH PRESERVE CT
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33436-5802
Country	:	US
Telephone Number	:	954-624-5649
Fax Number	:

Provider Business Practice Location Address
First Line	:	5058 GREENWICH PRESERVE CT
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33436-5802
Country	:	US
Telephone Number	:	954-624-5649
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. RETA GUIRGUIS
Credential	:	O.D.
Telephone Number	:	954-624-5649

Provider Enumeration Date	:	01/20/2015
Last Update Date	:	01/20/2015

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