MEDICARE: DR. THOMAS W GRANGE OD

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	915	NE
2	152W00000X	Optometrist	01937	IA
3	152W00000X	Optometrist	2081	MN

General Provider Information

NPI Number	:	1932155827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS W GRANGE OD

Provider Business Mailing Address
First Line	:	1103 GALVIN RD S
Second Line	:
City	:	BELLEVUE
State	:	NE
Zip	:	68005-3002
Country	:	US
Telephone Number	:	402-292-6514
Fax Number	:

Provider Business Practice Location Address
First Line	:	1103 GALVIN RD S
Second Line	:	SUITE H
City	:	BELLEVUE
State	:	NE
Zip	:	68005-3002
Country	:	US
Telephone Number	:	402-292-6514
Fax Number	:	402-292-7122

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	02/10/2010

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