MEDICARE: FREMONT VISION CORPORATION

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	885	NE

General Provider Information

NPI Number	:	1356532873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREMONT VISION CORPORATION

Provider Business Mailing Address
First Line	:	1625 E MILITARY AVE
Second Line	:
City	:	FREMONT
State	:	NE
Zip	:	68025-5463
Country	:	US
Telephone Number	:	402-721-0409
Fax Number	:	402-721-0409

Provider Business Practice Location Address
First Line	:	1625 E MILITARY AVE
Second Line	:
City	:	FREMONT
State	:	NE
Zip	:	68025-5463
Country	:	US
Telephone Number	:	402-721-0409
Fax Number	:	402-721-0409

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTOPHER G FORNOFF
Credential	:	O.D.
Telephone Number	:	402-721-0409

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	04/20/2008

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