MEDICARE: 2020 EYECARE LLC

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	152WC0802X	Corneal and Contact Management Optometrist
2	152W00000X	Optometrist

General Provider Information

NPI Number	:	1467077958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	2020 EYECARE LLC

Provider Business Mailing Address
First Line	:	9553 FIELDS ERTEL RD
Second Line	:
City	:	LOVELAND
State	:	OH
Zip	:	45140-7320
Country	:	US
Telephone Number	:	513-428-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	9553 FIELDS ERTEL RD
Second Line	:
City	:	LOVELAND
State	:	OH
Zip	:	45140-7320
Country	:	US
Telephone Number	:	513-428-2020
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. ALEX DAVID GIBBERMAN
Credential	:	OD
Telephone Number	:	513-470-4523

Provider Enumeration Date	:	06/10/2020
Last Update Date	:	06/10/2020

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