MEDICARE: EYE CENTER OF FORT SCOTT

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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1659596278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE CENTER OF FORT SCOTT

Provider Business Mailing Address
First Line	:	624 S NATIONAL AVE
Second Line	:
City	:	FORT SCOTT
State	:	KS
Zip	:	66701-1317
Country	:	US
Telephone Number	:	620-223-6440
Fax Number	:	620-223-6988

Provider Business Practice Location Address
First Line	:	624 S NATIONAL AVE
Second Line	:
City	:	FORT SCOTT
State	:	KS
Zip	:	66701-1317
Country	:	US
Telephone Number	:	620-223-6440
Fax Number	:	620-223-6988

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	DIANA D MITCHELL
Credential	:	CPOT
Telephone Number	:	620-223-6440

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	08/11/2008

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Practice Location Address:

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1831314459 — EYE CENTER OF FORT SCOTT
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Directions to “EYE CENTER OF FORT SCOTT ” Practice Location

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