MEDICARE: OPTICAL HEADQUARTERS

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	332900000X	Non-Pharmacy Dispensing Site

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

General Provider Information

NPI Number	:	1265633119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTICAL HEADQUARTERS

Provider Business Mailing Address
First Line	:	1710 FREDERICKSBURG RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78201-5033
Country	:	US
Telephone Number	:	210-735-3507
Fax Number	:	210-735-1811

Provider Business Practice Location Address
First Line	:	1710 FREDERICKSBURG RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78201-5033
Country	:	US
Telephone Number	:	210-735-3507
Fax Number	:	210-735-1811

Authorized Official
Title or Position	:	OWNER
Name	:	MR. LONNIE NEAL FUSSELL
Credential	:
Telephone Number	:	210-735-3507

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	06/27/2008

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Directions to “OPTICAL HEADQUARTERS ” Practice Location

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