MEDICARE: OPTOMETRIC VISION SERVICES PA

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	:	1861675290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTOMETRIC VISION SERVICES PA

Provider Business Mailing Address
First Line	:	150 E TRAVELERS TRL
Second Line	:	SUITE D
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-6889
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7000 YORK AVE S
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-4213
Country	:	US
Telephone Number	:	952-922-8118
Fax Number	:

Authorized Official
Title or Position	:	OFFICER
Name	:	GREG MACIK
Credential	:	OD
Telephone Number	:	952-913-7520

Provider Enumeration Date	:	12/07/2007
Last Update Date	:	12/07/2007

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