MEDICARE: OLDE TOWNE OPTICAL AND GIFTS 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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1346419777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLDE TOWNE OPTICAL AND GIFTS LLC

Provider Business Mailing Address
First Line	:	3012 W COLORADO AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-2147
Country	:	US
Telephone Number	:	719-636-3012
Fax Number	:	719-636-3014

Provider Business Practice Location Address
First Line	:	3012 W COLORADO AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-2147
Country	:	US
Telephone Number	:	719-636-3012
Fax Number	:	719-636-3014

Authorized Official
Title or Position	:	OWNER OPTICIAN
Name	:	MR. JOHN EDWARD DAUGHERTY
Credential	:	BA ABOC
Telephone Number	:	719-636-3012

Provider Enumeration Date	:	02/29/2008
Last Update Date	:	02/29/2008

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