MEDICARE: ICARELASVEGAS

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	557	NV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BH615A	OTHER	NV	MEDICARE PTAN

General Provider Information

NPI Number	:	1366606139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICARELASVEGAS

Provider Business Mailing Address
First Line	:	6134 W LAKE MEAD BLVD
Second Line	:	E-8
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2659
Country	:	US
Telephone Number	:	702-631-4144
Fax Number	:	702-631-9094

Provider Business Practice Location Address
First Line	:	6134 W LAKE MEAD BLVD
Second Line	:	E-8
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2659
Country	:	US
Telephone Number	:	702-631-4144
Fax Number	:	702-631-9094

Authorized Official
Title or Position	:	SOLE-MEMBER
Name	:	DR. GABRIEL HERNANDEZ
Credential	:	O.D.
Telephone Number	:	702-631-4144

Provider Enumeration Date	:	07/11/2008
Last Update Date	:	06/13/2012

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Directions to “ICARELASVEGAS ” Practice Location

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