MEDICARE: NORTHWEST EYECARE PROFESSIONALS LLC

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	5291 T2200	OH

General Provider Information

NPI Number	:	1831330976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST EYECARE PROFESSIONALS LLC

Provider Business Mailing Address
First Line	:	2098 TREMONT CTR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-3108
Country	:	US
Telephone Number	:	614-486-5205
Fax Number	:	614-486-0354

Provider Business Practice Location Address
First Line	:	2098 TREMONT CTR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-3108
Country	:	US
Telephone Number	:	614-486-5205
Fax Number	:	614-486-0354

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DR. DOUGLAS JOSEPH BOSNER
Credential	:	OD
Telephone Number	:	614-486-5205

Provider Enumeration Date	:	03/19/2009
Last Update Date	:	01/17/2012

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