MEDICARE: ADVANCED VISIONCARE OF MANSFIELD PA

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

General Provider Information

NPI Number	:	1447625975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED VISIONCARE OF MANSFIELD PA

Provider Business Mailing Address
First Line	:	4919 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1407
Country	:	US
Telephone Number	:	817-370-2100
Fax Number	:	817-370-2113

Provider Business Practice Location Address
First Line	:	4919 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1407
Country	:	US
Telephone Number	:	817-370-2100
Fax Number	:	817-370-2113

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAMES K SMITH
Credential	:	OD
Telephone Number	:	817-370-2100

Provider Enumeration Date	:	12/09/2015
Last Update Date	:	12/09/2015

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