MEDICARE: THE CONTACT LENS AND EYECARE CLINIC, INC.

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	OD2046	WA

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	:	1881761351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CONTACT LENS AND EYECARE CLINIC, INC.

Provider Business Mailing Address
First Line	:	114 E 1ST ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-2903
Country	:	US
Telephone Number	:	360-452-2361
Fax Number	:	360-452-2362

Provider Business Practice Location Address
First Line	:	114 E 1ST ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-2903
Country	:	US
Telephone Number	:	360-452-2361
Fax Number	:	360-452-2362

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LAWRENCE WILLIAM NIVALA
Credential	:	OD
Telephone Number	:	360-452-2361

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	02/12/2008

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