MEDICARE: IMAGE OPTICAL, 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	332B00000X	Durable Medical Equipment & Medical Supplies	388	KY

General Provider Information

NPI Number	:	1881840221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMAGE OPTICAL, INC

Provider Business Mailing Address
First Line	:	4121 OECHSLI AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-5022
Country	:	US
Telephone Number	:	502-895-8135
Fax Number	:	502-895-8133

Provider Business Practice Location Address
First Line	:	4121 OECHSLI AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-5022
Country	:	US
Telephone Number	:	502-895-8135
Fax Number	:	502-895-8133

Authorized Official
Title or Position	:	PRESIDENT/OPTICIAN
Name	:	JON RICHARD PAULINE
Credential	:	LICENSED OPTICIAN
Telephone Number	:	502-895-8135

Provider Enumeration Date	:	08/18/2008
Last Update Date	:	08/18/2008

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