MEDICARE: AVIDI DEFINITIVE EYEWEAR, 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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1851474811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVIDI DEFINITIVE EYEWEAR, LLC

Provider Business Mailing Address
First Line	:	7519 N MAY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-3203
Country	:	US
Telephone Number	:	405-843-8434
Fax Number	:	405-840-2806

Provider Business Practice Location Address
First Line	:	7519 N MAY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-3203
Country	:	US
Telephone Number	:	405-843-8434
Fax Number	:	405-840-2806

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. MAURICE MARK MYLES
Credential	:
Telephone Number	:	405-842-8434

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	08/22/2020

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