MEDICARE: MRS. AMY B INTERNICOLA 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	156FC0801X	Contact Lens Fitter	C005694-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C005694-1	OTHER	NY	LICENSED OPTICIAN

General Provider Information

NPI Number	:	1700099785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY B INTERNICOLA LICENSED OPTICIAN

Provider Business Mailing Address
First Line	:	2441 SHERIDAN DR
Second Line	:
City	:	TONAWANDA
State	:	NY
Zip	:	14150-9405
Country	:	US
Telephone Number	:	716-836-8700
Fax Number	:	716-836-3549

Provider Business Practice Location Address
First Line	:	2441 SHERIDAN DR
Second Line	:
City	:	TONAWANDA
State	:	NY
Zip	:	14150-9405
Country	:	US
Telephone Number	:	716-836-8700
Fax Number	:	716-836-3549

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

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	07/08/2007

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