MEDICARE: P D LAB INC

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	DO1062	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720100399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P D LAB INC

Provider Business Mailing Address
First Line	:	6169 JOG RD
Second Line	:	STE A3
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-6579
Country	:	US
Telephone Number	:	561-304-1234
Fax Number	:	561-304-1254

Provider Business Practice Location Address
First Line	:	6169 JOG RD
Second Line	:	STE A3
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-6579
Country	:	US
Telephone Number	:	561-304-1234
Fax Number	:	561-304-1254

Authorized Official
Title or Position	:	PRESIDENT OPTICIAN
Name	:	MR. PETER FOX
Credential	:
Telephone Number	:	561-304-1234

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	08/02/2010

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Directions to “P D LAB INC ” Practice Location

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