MEDICARE: MIRACLE VISION OPTICAL

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	DR4082	TX

General Provider Information

NPI Number	:	1962683557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRACLE VISION OPTICAL

Provider Business Mailing Address
First Line	:	4042 MIHO
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223-3822
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4042 MIHO
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223-3822
Country	:	US
Telephone Number	:	210-337-5243
Fax Number	:

Authorized Official
Title or Position	:	CERTIFIED OPTICIAN
Name	:	MR. ADRIAN CASTANEDA
Credential	:
Telephone Number	:	210-337-5843

Provider Enumeration Date	:	11/24/2007
Last Update Date	:	11/24/2007

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Directions to “MIRACLE VISION OPTICAL ” Practice Location

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