MEDICARE: MR. CODY BENTON MASTERS OPTICIAN

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

General Provider Information

NPI Number	:	1952633372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CODY BENTON MASTERS OPTICIAN

Provider Business Mailing Address
First Line	:	920 S BRYANT AVE STE 101
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73034-5803
Country	:	US
Telephone Number	:	405-341-6588
Fax Number	:	405-348-9537

Provider Business Practice Location Address
First Line	:	920 S BRYANT AVE STE 101
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73034-5803
Country	:	US
Telephone Number	:	405-341-6588
Fax Number	:	405-348-9537

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

Provider Enumeration Date	:	02/10/2010
Last Update Date	:	02/10/2010

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