MEDICARE: MEI SAN LAM O.D.

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	8299T	TX

General Provider Information

NPI Number	:	1356774392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEI SAN LAM O.D.

Provider Business Mailing Address
First Line	:	4206 KEMP BLVD
Second Line	:	STE. B
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308-2845
Country	:	US
Telephone Number	:	940-696-2653
Fax Number	:

Provider Business Practice Location Address
First Line	:	4206 KEMP BLVD
Second Line	:	STE. B
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308-2845
Country	:	US
Telephone Number	:	940-696-2653
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2013
Last Update Date	:	04/14/2015

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