MEDICARE: EXPRESS VISION CARE, 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	332H00000X	Eyewear Supplier	DO6361	FL

General Provider Information

NPI Number	:	1912255365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXPRESS VISION CARE, INC.

Provider Business Mailing Address
First Line	:	1550 W 84TH ST STE 15
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33014-3368
Country	:	US
Telephone Number	:	786-587-7404
Fax Number	:

Provider Business Practice Location Address
First Line	:	1550 W 84TH ST STE 15
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33014-3368
Country	:	US
Telephone Number	:	786-587-7404
Fax Number	:

Authorized Official
Title or Position	:	OPTICIAN
Name	:	RAUL LOPEZ
Credential	:	LDO
Telephone Number	:	786-587-7404

Provider Enumeration Date	:	08/16/2012
Last Update Date	:	08/16/2012

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