MEDICARE: MAHALIA LEONTINE GOODMAN EYE SPECIALIST

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	156FX1202X	Optometric Technician

General Provider Information

NPI Number	:	1275169088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAHALIA LEONTINE GOODMAN EYE SPECIALIST

Provider Business Mailing Address
First Line	:	301 ANDREWS AVE
Second Line	:
City	:	FORT RUCKER
State	:	AL
Zip	:	36362
Country	:	US
Telephone Number	:	800-261-7193
Fax Number	:	334-255-7710

Provider Business Practice Location Address
First Line	:	301 ANDREWS AVE
Second Line	:
City	:	FORT RUCKER
State	:	AL
Zip	:	36362
Country	:	US
Telephone Number	:	800-261-7193
Fax Number	:	334-255-7710

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

Provider Enumeration Date	:	03/13/2020
Last Update Date	:	03/13/2020

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