MEDICARE: LAWRENCE ALAN CARROLL 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	DO889	FL

General Provider Information

NPI Number	:	1487772935
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWRENCE ALAN CARROLL OPTICIAN

Provider Business Mailing Address
First Line	:	3710 SAINT JOHNS AVE
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-4026
Country	:	US
Telephone Number	:	386-328-2020
Fax Number	:	386-328-6430

Provider Business Practice Location Address
First Line	:	3710 SAINT JOHNS AVE
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-4026
Country	:	US
Telephone Number	:	386-328-2020
Fax Number	:	386-328-6430

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

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	01/23/2008

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