MEDICARE: LAKE TRAVIS EYE AND LASER CENTER, PA

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	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1629382023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE TRAVIS EYE AND LASER CENTER, PA

Provider Business Mailing Address
First Line	:	3503 WILD CHERRY DR BLDG 3
Second Line	:
City	:	LAKEWAY
State	:	TX
Zip	:	78738-1817
Country	:	US
Telephone Number	:	512-263-9000
Fax Number	:	512-263-9126

Provider Business Practice Location Address
First Line	:	3503 WILD CHERRY DR BLDG 3
Second Line	:
City	:	LAKEWAY
State	:	TX
Zip	:	78738-1817
Country	:	US
Telephone Number	:	512-263-9000
Fax Number	:	512-263-9126

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KYLE RHODES
Credential	:	MD
Telephone Number	:	512-263-9000

Provider Enumeration Date	:	07/28/2010
Last Update Date	:	10/30/2019

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