MEDICARE: RAY BLACKFORD 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	47	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OP1147	OTHER	AK	DISPENSING OPTICIAN LICEN

General Provider Information

NPI Number	:	1780737882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAY BLACKFORD OPTICIAN

Provider Business Mailing Address
First Line	:	3744 LAKE OTIS PKWY
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-5208
Country	:	US
Telephone Number	:	907-563-5118
Fax Number	:	907-561-7140

Provider Business Practice Location Address
First Line	:	3744 LAKE OTIS PKWY
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-5208
Country	:	US
Telephone Number	:	907-563-5118
Fax Number	:	907-561-7140

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

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	07/08/2007

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