MEDICARE: GEORGE OPTICAL CO. 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	156FX1800X	Optician	C004400-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	00026744401	OTHER	UNIVERA
2	00300164001	OTHER	BC/BS
3	NY4300	OTHER	EYEMED VISION CARE
4	7309985	OTHER	INDEPENDENT HEALTH

General Provider Information

NPI Number	:	1902881212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGE OPTICAL CO. INC.

Provider Business Mailing Address
First Line	:	PO BOX 927
Second Line	:
City	:	NIAGARA FALLS
State	:	NY
Zip	:	14302-0927
Country	:	US
Telephone Number	:	716-282-7377
Fax Number	:	716-282-7382

Provider Business Practice Location Address
First Line	:	1523 PINE AVE
Second Line	:
City	:	NIAGARA FALLS
State	:	NY
Zip	:	14301-2209
Country	:	US
Telephone Number	:	716-282-7377
Fax Number	:	716-282-7382

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JAMES LOUIS FERNANDEZ
Credential	:	OPTICIAN
Telephone Number	:	716-282-7377

Provider Enumeration Date	:	12/08/2005
Last Update Date	:	06/13/2008

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