MEDICARE: EYEWEAR CENTER OF FLAGLER COUNTY 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	332B00000X	Durable Medical Equipment & Medical Supplies	DO1099	FL

General Provider Information

NPI Number	:	1346423902
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYEWEAR CENTER OF FLAGLER COUNTY INC.

Provider Business Mailing Address
First Line	:	50 CYPRESS POINT PKWY
Second Line	:	SUITE C3-4
City	:	PALM COAST
State	:	FL
Zip	:	32164-2500
Country	:	US
Telephone Number	:	386-446-2020
Fax Number	:	386-446-6098

Provider Business Practice Location Address
First Line	:	50 CYPRESS POINT PKWY
Second Line	:	SUITE C3-4
City	:	PALM COAST
State	:	FL
Zip	:	32164-2500
Country	:	US
Telephone Number	:	386-446-2020
Fax Number	:	386-446-6098

Authorized Official
Title or Position	:	MASTER OPTICIAN
Name	:	MR. CRAIG ALLAN HENDERSON
Credential	:
Telephone Number	:	386-446-2020

Provider Enumeration Date	:	12/06/2007
Last Update Date	:	12/06/2007

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