MEDICARE: DR. BERT ROGER FREWING O.D.

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	972ATI	OR

General Provider Information

NPI Number	:	1346310752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BERT ROGER FREWING O.D.

Provider Business Mailing Address
First Line	:	1602 4TH ST
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-2506
Country	:	US
Telephone Number	:	541-963-6224
Fax Number	:	541-975-2114

Provider Business Practice Location Address
First Line	:	1602 4TH ST
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-2506
Country	:	US
Telephone Number	:	541-963-6224
Fax Number	:	541-975-2114

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

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	07/08/2007

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