MEDICARE: DR. DALE G LERVICK OD

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	777	CO

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	32959	OTHER	CO	BLUE CROSS

General Provider Information

NPI Number	:	1326047077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALE G LERVICK OD

Provider Business Mailing Address
First Line	:	7586 W JEWELL AVE
Second Line	:	SUITE 104
City	:	LAKEWOOD
State	:	CO
Zip	:	80232-6890
Country	:	US
Telephone Number	:	303-233-7575
Fax Number	:	303-233-4740

Provider Business Practice Location Address
First Line	:	7586 W JEWELL AVE
Second Line	:	SUITE 104
City	:	LAKEWOOD
State	:	CO
Zip	:	80232-6890
Country	:	US
Telephone Number	:	303-233-7575
Fax Number	:	303-233-4740

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	04/25/2012

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