MEDICARE: FORT MADISON LENSCRAFTERS

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	01719	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	24695	OTHER	IA	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902093156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT MADISON LENSCRAFTERS

Provider Business Mailing Address
First Line	:	716 AVENUE G
Second Line	:
City	:	FORT MADISON
State	:	IA
Zip	:	52627-2927
Country	:	US
Telephone Number	:	319-372-2321
Fax Number	:

Provider Business Practice Location Address
First Line	:	716 AVENUE G
Second Line	:
City	:	FORT MADISON
State	:	IA
Zip	:	52627-2927
Country	:	US
Telephone Number	:	319-372-2321
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. LARRY DON PECK
Credential	:	OD
Telephone Number	:	319-372-2321

Provider Enumeration Date	:	10/02/2007
Last Update Date	:	10/02/2007

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