MEDICARE: OPTICAL EAST 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	156FX1800X	Optician	299	AZ

General Provider Information

NPI Number	:	1639225493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTICAL EAST INC

Provider Business Mailing Address
First Line	:	4419 E MAIN #109
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205
Country	:	US
Telephone Number	:	480-830-1292
Fax Number	:	480-924-9042

Provider Business Practice Location Address
First Line	:	4419 E MAIN ST STE 109
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-7900
Country	:	US
Telephone Number	:	480-830-1292
Fax Number	:	480-924-9042

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MRS. SHIRLEY A RAKOWSKY
Credential	:	LDO
Telephone Number	:	480-830-1292

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	04/14/2008

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Directions to “OPTICAL EAST INC ” Practice Location

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