MEDICARE: COUNTRYWAY EYECARE

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	OP3810	FL

General Provider Information

NPI Number	:	1629493887
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRYWAY EYECARE

Provider Business Mailing Address
First Line	:	6911 PISTOL RANGE RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33635-6335
Country	:	US
Telephone Number	:	813-925-3393
Fax Number	:	813-925-3394

Provider Business Practice Location Address
First Line	:	6911 PISTOL RANGE RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33635-6335
Country	:	US
Telephone Number	:	813-925-3393
Fax Number	:	813-925-3394

Authorized Official
Title or Position	:	PRES
Name	:	DR. TARA RUSOFF
Credential	:	O.D.
Telephone Number	:	813-925-3393

Provider Enumeration Date	:	02/25/2014
Last Update Date	:	02/25/2014

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Directions to “COUNTRYWAY EYECARE ” Practice Location

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