MEDICARE: VISIONARY EYECARE CENTER LLC

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	9206TG	TX

General Provider Information

NPI Number	:	1326552985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISIONARY EYECARE CENTER LLC

Provider Business Mailing Address
First Line	:	1342 WOODBROOK CT
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-4835
Country	:	US
Telephone Number	:	817-932-2498
Fax Number	:

Provider Business Practice Location Address
First Line	:	1217 OAK KNOLL DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76117-5505
Country	:	US
Telephone Number	:	817-932-2498
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. ALISHA POONAWALA
Credential	:	OD
Telephone Number	:	817-932-2498

Provider Enumeration Date	:	11/18/2017
Last Update Date	:	01/09/2018

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