MEDICARE: THE EYE GALLERY DC, LLC

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

General Provider Information

NPI Number	:	1992934301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE EYE GALLERY DC, LLC

Provider Business Mailing Address
First Line	:	700 PIER PARK DR
Second Line	:	STE 110
City	:	PANAMA CITY
State	:	FL
Zip	:	32413-2168
Country	:	US
Telephone Number	:	850-387-4799
Fax Number	:	850-230-8350

Provider Business Practice Location Address
First Line	:	700 PIER PARK DR
Second Line	:	STE 110
City	:	PANAMA CITY
State	:	FL
Zip	:	32413-2168
Country	:	US
Telephone Number	:	850-387-4799
Fax Number	:	850-230-8350

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. LARRY BURGER
Credential	:
Telephone Number	:	850-357-4799

Provider Enumeration Date	:	07/07/2009
Last Update Date	:	07/07/2009

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