MEDICARE: MR. JONNY B FUENTES ABOC

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	156FX1800X	Optician

General Provider Information

NPI Number	:	1215194634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONNY B FUENTES ABOC

Provider Business Mailing Address
First Line	:	5800 BELLAIRE BLVD
Second Line	:	STE 112
City	:	HOUSTON
State	:	TX
Zip	:	77081-5537
Country	:	US
Telephone Number	:	713-771-7867
Fax Number	:	713-771-7869

Provider Business Practice Location Address
First Line	:	5800 BELLAIRE BLVD
Second Line	:	STE 112
City	:	HOUSTON
State	:	TX
Zip	:	77081-5537
Country	:	US
Telephone Number	:	713-771-7867
Fax Number	:	713-771-7869

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

Provider Enumeration Date	:	05/22/2008
Last Update Date	:	08/24/2011

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