MEDICARE: MEL DALLAS LOVE FIELD 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	152W00000X	Optometrist
2	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1528722527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEL DALLAS LOVE FIELD LLC

Provider Business Mailing Address
First Line	:	1784 W MCDERMOTT DR STE 110
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75013-3396
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3701 W NORTHWEST HWY STE 430
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75220-4955
Country	:	US
Telephone Number	:	956-335-6476
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF MANAGED CARE
Name	:	DANIEL GARZA
Credential	:
Telephone Number	:	561-433-6009

Provider Enumeration Date	:	10/26/2021
Last Update Date	:	10/26/2021

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Directions to “MEL DALLAS LOVE FIELD LLC ” Practice Location

Language	Start Address	Practice Location

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