MEDICARE: ADVANCED VISIONCARE OF FORT WORTH 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	4711T	TX

General Provider Information

NPI Number	:	1891096962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED VISIONCARE OF FORT WORTH PA

Provider Business Mailing Address
First Line	:	4919 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1407
Country	:	US
Telephone Number	:	817-370-2100
Fax Number	:	817-539-8035

Provider Business Practice Location Address
First Line	:	4919 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1407
Country	:	US
Telephone Number	:	817-370-2100
Fax Number	:	817-539-8035

Authorized Official
Title or Position	:	MANAGER
Name	:	JAMES KEVIN SMITH
Credential	:
Telephone Number	:	817-370-2100

Provider Enumeration Date	:	11/05/2010
Last Update Date	:	11/05/2010

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