MEDICARE: DR. TERRANCE PETER CARMINE O.D.

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	46-6715	IL

General Provider Information

NPI Number	:	1740361443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRANCE PETER CARMINE O.D.

Provider Business Mailing Address
First Line	:	3224 RIDGE RD
Second Line	:
City	:	LANSING
State	:	IL
Zip	:	60438-3129
Country	:	US
Telephone Number	:	708-895-4422
Fax Number	:	708-895-4482

Provider Business Practice Location Address
First Line	:	3224 RIDGE RD
Second Line	:
City	:	LANSING
State	:	IL
Zip	:	60438-3129
Country	:	US
Telephone Number	:	708-895-4422
Fax Number	:	708-895-4482

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

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	10/27/2010

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