MEDICARE: THE LASIK VISION INSTITUTE LLC

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	261QS0132X	Ophthalmologic Surgery Clinic/Center

General Provider Information

NPI Number	:	1902351166
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE LASIK VISION INSTITUTE LLC

Provider Business Mailing Address
First Line	:	1555 PALM BEACH LAKES BLVD
Second Line	:	SUITE 600
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-2323
Country	:	US
Telephone Number	:	800-584-4150
Fax Number	:

Provider Business Practice Location Address
First Line	:	4150 INTERNATIONAL PLZ
Second Line	:	SUITE 150
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4892
Country	:	US
Telephone Number	:	817-763-8872
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BEN COOK
Credential	:
Telephone Number	:	800-584-4150

Provider Enumeration Date	:	08/17/2016
Last Update Date	:	08/17/2016

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