MEDICARE: MODERN OPTICAL EYEWEAR, INC.

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	332H00000X	Eyewear Supplier	332H00000X	IL

General Provider Information

NPI Number	:	1346384450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN OPTICAL EYEWEAR, INC.

Provider Business Mailing Address
First Line	:	2812 W FOSTER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3506
Country	:	US
Telephone Number	:	773-784-6300
Fax Number	:	773-360-9589

Provider Business Practice Location Address
First Line	:	2812 W FOSTER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3506
Country	:	US
Telephone Number	:	773-784-6300
Fax Number	:	773-360-9589

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JOHN MANIATAKIS
Credential	:
Telephone Number	:	773-784-6300

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	04/07/2008

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