MEDICARE: SUCCESS VISION SERVICES, 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	2049	OK

General Provider Information

NPI Number	:	1699911024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUCCESS VISION SERVICES, LLC

Provider Business Mailing Address
First Line	:	5312 W 41 ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74107-6110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5312 W 41ST ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74107-6110
Country	:	US
Telephone Number	:	918-794-9029
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	MR. MARK T PLATH
Credential	:
Telephone Number	:	918-834-2929

Provider Enumeration Date	:	01/07/2009
Last Update Date	:	01/09/2009

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