MEDICARE: ALICIA'S EYEWEAR BOUTIQUE

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841376258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALICIA'S EYEWEAR BOUTIQUE

Provider Business Mailing Address
First Line	:	10128 SAINT CLAIR AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-1963
Country	:	US
Telephone Number	:	216-761-6055
Fax Number	:	216-761-6056

Provider Business Practice Location Address
First Line	:	10128 SAINT CLAIR AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-1963
Country	:	US
Telephone Number	:	216-761-6055
Fax Number	:	216-761-6056

Authorized Official
Title or Position	:	OWNER
Name	:	ALICIA FORD
Credential	:	OPTICIAN
Telephone Number	:	216-761-6055

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	06/13/2008

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