MEDICARE: EYEGLASS WORLD, LLC 86

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	:	1356560601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYEGLASS WORLD, LLC 86

Provider Business Mailing Address
First Line	:	3801 S CONGRESS AVE
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-4140
Country	:	US
Telephone Number	:	561-965-9110
Fax Number	:	561-642-4063

Provider Business Practice Location Address
First Line	:	1281 POLARIS PKWY
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43240-2037
Country	:	US
Telephone Number	:	614-433-0231
Fax Number	:	614-436-2241

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BEN COOK
Credential	:
Telephone Number	:	561-965-9110

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	07/11/2007

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