MEDICARE: PBW OPTOMETRY P C

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	152WC0802X	Corneal and Contact Management Optometrist	AZ178	AZ

General Provider Information

NPI Number	:	1255468930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PBW OPTOMETRY P C

Provider Business Mailing Address
First Line	:	2215 HUALAPAI MOUNTAIN RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-8324
Country	:	US
Telephone Number	:	928-718-1009
Fax Number	:

Provider Business Practice Location Address
First Line	:	2215 HUALAPAI MOUNTAIN RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-8324
Country	:	US
Telephone Number	:	928-718-1009
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LAWRENCE A PEARL
Credential	:	O D
Telephone Number	:	602-524-7618

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	08/22/2020

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