MEDICARE: OPTIMAL VISION OPTOMETRY 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

General Provider Information

NPI Number	:	1609498856
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL VISION OPTOMETRY LLC

Provider Business Mailing Address
First Line	:	11841 PALM BEACH BLVD UNIT 117
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-5914
Country	:	US
Telephone Number	:	239-500-2020
Fax Number	:	239-500-2030

Provider Business Practice Location Address
First Line	:	11841 PALM BEACH BLVD UNIT 117
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-5914
Country	:	US
Telephone Number	:	239-500-2020
Fax Number	:	239-500-2030

Authorized Official
Title or Position	:	MGRM
Name	:	BRITTANY ANN DEGLER
Credential	:	OD
Telephone Number	:	239-500-2020

Provider Enumeration Date	:	05/11/2020
Last Update Date	:	03/29/2021

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