=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013103175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTICAL DESIGN, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2007
-----------------------------------------------------
Last Update Date | 09/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1530 W GLENDALE AVE #101
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85021-8578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-995-5883
-----------------------------------------------------
Fax | 602-995-3365
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1530 W GLENDALE AVE #101
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85021-8578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-995-5883
-----------------------------------------------------
Fax | 602-995-3365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN
-----------------------------------------------------
Name | MRS. S C JOINER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-995-5883
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 269
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------