MEDICARE: MRS. ROBIN SHIVERDECKER LICENSED OPTICIAN

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	5728S	OH

General Provider Information

NPI Number	:	1669646246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ROBIN SHIVERDECKER LICENSED OPTICIAN

Provider Business Mailing Address
First Line	:	PO BOX 658
Second Line	:
City	:	LEWISBURG
State	:	OH
Zip	:	45338-0658
Country	:	US
Telephone Number	:	937-962-4444
Fax Number	:	937-962-4443

Provider Business Practice Location Address
First Line	:	210 N COMMERCE ST
Second Line	:
City	:	LEWISBURG
State	:	OH
Zip	:	45338-9343
Country	:	US
Telephone Number	:	937-962-4444
Fax Number	:	937-962-4443

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2008
Last Update Date	:	04/15/2008

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