MEDICARE: THEODORE G. CROOK INC.

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	0413	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255314274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THEODORE G. CROOK INC.

Provider Business Mailing Address
First Line	:	408 DEKALB ST
Second Line	:	SUITE C
City	:	CAMDEN
State	:	SC
Zip	:	29020-4429
Country	:	US
Telephone Number	:	803-424-1142
Fax Number	:

Provider Business Practice Location Address
First Line	:	408 DEKALB ST
Second Line	:	SUITE C
City	:	CAMDEN
State	:	SC
Zip	:	29020-4429
Country	:	US
Telephone Number	:	803-424-1142
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. THEODORE G CROOK
Credential	:	O.D.
Telephone Number	:	803-424-1142

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	08/12/2008

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