MEDICARE: KIRK OPTOMETRY, 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	261Q00000X	Clinic/Center	OEG002194	PA

General Provider Information

NPI Number	:	1508165242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIRK OPTOMETRY, LLC

Provider Business Mailing Address
First Line	:	567 CREEKSIDE LN
Second Line	:
City	:	LITITZ
State	:	PA
Zip	:	17543-6813
Country	:	US
Telephone Number	:	804-301-1969
Fax Number	:	717-757-2350

Provider Business Practice Location Address
First Line	:	2899 WHITEFORD RD
Second Line	:	BOSCOV'S OPTICAL DEPARTMENT
City	:	YORK
State	:	PA
Zip	:	17402-8902
Country	:	US
Telephone Number	:	717-755-4395
Fax Number	:	717-757-2350

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TARA JOANNE WEISBECK KIRK
Credential	:	O.D.
Telephone Number	:	804-301-1969

Provider Enumeration Date	:	03/21/2011
Last Update Date	:	03/21/2011

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