MEDICARE: TAMMY LOUISE KING

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	:	1255462933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMY LOUISE KING

Provider Business Mailing Address
First Line	:	1960 CLIFF LAKE RD
Second Line	:	SUITE 119
City	:	EAGAN
State	:	MN
Zip	:	55122-2476
Country	:	US
Telephone Number	:	651-287-1400
Fax Number	:	651-287-0110

Provider Business Practice Location Address
First Line	:	1960 CLIFF LAKE RD
Second Line	:	SUITE 119
City	:	EAGAN
State	:	MN
Zip	:	55122-2476
Country	:	US
Telephone Number	:	651-287-1400
Fax Number	:	651-287-0110

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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