MEDICARE: DR. RICKI-LEE HALLING O.D.

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	1576	AZ

General Provider Information

NPI Number	:	1972779817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICKI-LEE HALLING O.D.

Provider Business Mailing Address
First Line	:	PO BOX 3136
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86405-3136
Country	:	US
Telephone Number	:	928-486-7527
Fax Number	:

Provider Business Practice Location Address
First Line	:	2730 VIA PALMA
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86406-7730
Country	:	US
Telephone Number	:	928-486-7527
Fax Number	:

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

Provider Enumeration Date	:	04/30/2008
Last Update Date	:	04/30/2008

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