MEDICARE: DR. AUDRY LYNN POQUETTE 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	4901004657	MI

General Provider Information

NPI Number	:	1568742229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AUDRY LYNN POQUETTE O.D.

Provider Business Mailing Address
First Line	:	200 FAIRBANKS ST
Second Line	:	STE 1
City	:	IRON MOUNTAIN
State	:	MI
Zip	:	49801-1510
Country	:	US
Telephone Number	:	906-774-8280
Fax Number	:	906-774-8290

Provider Business Practice Location Address
First Line	:	200 FAIRBANKS ST
Second Line	:	STE 1
City	:	IRON MOUNTAIN
State	:	MI
Zip	:	49801-1510
Country	:	US
Telephone Number	:	906-774-8280
Fax Number	:	906-774-8290

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

Provider Enumeration Date	:	08/25/2011
Last Update Date	:	10/26/2016

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