MEDICARE: OPTIC GALLERY NELLIS 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	580	NV

General Provider Information

NPI Number	:	1639670011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIC GALLERY NELLIS LLC

Provider Business Mailing Address
First Line	:	111 N NELLIS BLVD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-6010
Country	:	US
Telephone Number	:	702-820-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 N NELLIS BLVD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-6010
Country	:	US
Telephone Number	:	702-820-2020
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPTOMETRIS
Name	:	MELISSA BEATY
Credential	:	OD
Telephone Number	:	702-820-2020

Provider Enumeration Date	:	02/22/2018
Last Update Date	:	02/22/2018

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