MEDICARE: DR. TIMOTHY DALE HENDRICKS 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	OPT 002025	GA
2	152W00000X	Optometrist	SC 1345	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487753141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY DALE HENDRICKS O.D.

Provider Business Mailing Address
First Line	:	1000 TOWNE CENTER BLVD
Second Line	:	SUITE 502
City	:	POOLER
State	:	GA
Zip	:	31322-4052
Country	:	US
Telephone Number	:	912-748-1272
Fax Number	:	912-748-1996

Provider Business Practice Location Address
First Line	:	1000 TOWNE CENTER BLVD
Second Line	:	SUITE 502
City	:	POOLER
State	:	GA
Zip	:	31322-4052
Country	:	US
Telephone Number	:	912-748-1272
Fax Number	:	912-748-1996

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/08/2007

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