MEDICARE: LAIRCEY EYE SERVICES PC

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	OPT 002175	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GRP6825	OTHER	GA	MEDICARE GROUP
2	P00223010	OTHER	GA	RR MEDICARE INDIVIDUAL
3	DD3540	OTHER	GA	RR MEDICARE GROUP

General Provider Information

NPI Number	:	1831389949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAIRCEY EYE SERVICES PC

Provider Business Mailing Address
First Line	:	820 HWY 80 E
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30461-0800
Country	:	US
Telephone Number	:	912-489-3937
Fax Number	:

Provider Business Practice Location Address
First Line	:	820 HWY 80 E
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30461-0800
Country	:	US
Telephone Number	:	912-489-3937
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRENT C LAIRCEY
Credential	:	OD
Telephone Number	:	912-489-3937

Provider Enumeration Date	:	07/26/2007
Last Update Date	:	04/20/2008

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Directions to “LAIRCEY EYE SERVICES PC ” Practice Location

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