MEDICARE: MR. MICHELAIRE EMILE 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	DO4560	FL

General Provider Information

NPI Number	:	1578574208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHELAIRE EMILE OPTICIAN

Provider Business Mailing Address
First Line	:	14030 W DIXIE HWY
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33161-3443
Country	:	US
Telephone Number	:	305-981-4775
Fax Number	:	305-981-4766

Provider Business Practice Location Address
First Line	:	14030 W DIXIE HWY
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33161-3443
Country	:	US
Telephone Number	:	305-981-4775
Fax Number	:	305-981-4766

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

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	07/08/2007

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