MEDICARE: EAST LAKE EYECARE & EYEWEAR 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	3810	FL

General Provider Information

NPI Number	:	1578633442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST LAKE EYECARE & EYEWEAR INC

Provider Business Mailing Address
First Line	:	3434 E LAKE RD STE 3
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34685-2401
Country	:	US
Telephone Number	:	727-781-7922
Fax Number	:

Provider Business Practice Location Address
First Line	:	3434 E LAKE RD STE 3
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34685-2401
Country	:	US
Telephone Number	:	727-781-7922
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TARA M RUSOFF
Credential	:	O.D.
Telephone Number	:	727-781-7922

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	09/20/2014

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