MEDICARE: EYE SURGEONS OF RICHMOND, INC.

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	:	1528336385
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE SURGEONS OF RICHMOND, INC.

Provider Business Mailing Address
First Line	:	400 WESTHAMPTON STA
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23226-3330
Country	:	US
Telephone Number	:	804-287-4200
Fax Number	:	804-287-4210

Provider Business Practice Location Address
First Line	:	12018 W BROAD ST
Second Line	:	SUITE 100
City	:	HENRICO
State	:	VA
Zip	:	23233-7689
Country	:	US
Telephone Number	:	804-287-4200
Fax Number	:	804-287-4210

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. EDDIE F CLARK
Credential	:
Telephone Number	:	804-287-4236

Provider Enumeration Date	:	12/08/2011
Last Update Date	:	12/08/2011

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