MEDICARE: PROMENADE EYE CARE, 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	OPC 4633	FL

General Provider Information

NPI Number	:	1225457716
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROMENADE EYE CARE, LLC

Provider Business Mailing Address
First Line	:	4413 LYONS RD
Second Line	:	SUITE 101 DOCTORS OF OPTOMETRY NEXT TO LENSCRAFTERS
City	:	COCONUT CREEK
State	:	FL
Zip	:	33073-4383
Country	:	US
Telephone Number	:	954-975-9181
Fax Number	:	954-975-9597

Provider Business Practice Location Address
First Line	:	4413 LYONS RD
Second Line	:	SUITE 101 DOCTORS OF OPTOMETRY NEXT TO LENSCRAFTERS
City	:	COCONUT CREEK
State	:	FL
Zip	:	33073-4383
Country	:	US
Telephone Number	:	954-975-9181
Fax Number	:	954-975-9597

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. ANISA KRISTOLLARI
Credential	:
Telephone Number	:	954-975-9181

Provider Enumeration Date	:	04/11/2014
Last Update Date	:	04/11/2014

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