MEDICARE: VELVET PREWITT LICENSED OPTICIAN

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	156FX1800X	Optician	L-930710	AR

General Provider Information

NPI Number	:	1376620559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VELVET PREWITT LICENSED OPTICIAN

Provider Business Mailing Address
First Line	:	2511 HARRISON ST
Second Line	:
City	:	BATESVILLE
State	:	AR
Zip	:	72501-7424
Country	:	US
Telephone Number	:	870-698-2020
Fax Number	:	870-698-9371

Provider Business Practice Location Address
First Line	:	2511 HARRISON ST
Second Line	:
City	:	BATESVILLE
State	:	AR
Zip	:	72501-7424
Country	:	US
Telephone Number	:	870-698-2020
Fax Number	:	870-698-9371

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	01/10/2008

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