MEDICARE: EYELAND OPTICAL 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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1831310788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYELAND OPTICAL INC

Provider Business Mailing Address
First Line	:	851 E 23RD ST
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-5311
Country	:	US
Telephone Number	:	850-215-3937
Fax Number	:	850-215-7337

Provider Business Practice Location Address
First Line	:	851 E 23RD ST
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-5311
Country	:	US
Telephone Number	:	850-215-3937
Fax Number	:	850-215-3937

Authorized Official
Title or Position	:	OWNER OPTOMETRIST
Name	:	DR. BRENDA A WAINWRIGHT
Credential	:	OD
Telephone Number	:	850-215-3937

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	01/18/2012

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