MEDICARE: THE LASIK VISION INSTITUTE 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

General Provider Information

NPI Number	:	1669513388
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE LASIK VISION INSTITUTE LLC

Provider Business Mailing Address
First Line	:	2000 PALM BEACH LAKES BLVD
Second Line	:	STE 800
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-6503
Country	:	US
Telephone Number	:	561-965-9110
Fax Number	:	706-243-4627

Provider Business Practice Location Address
First Line	:	4750 BRYANT IRVIN RD
Second Line	:	STE 812
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3633
Country	:	US
Telephone Number	:	817-263-6798
Fax Number	:	817-263-6797

Authorized Official
Title or Position	:	COO
Name	:	BEN COOK
Credential	:
Telephone Number	:	561-965-9110

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	11/17/2011

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