=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013117019
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY REED DACANAL, OD INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2007
-----------------------------------------------------
Last Update Date | 02/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 516 MARKET ST
-----------------------------------------------------
City | JOHNSONBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15845-1240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-965-3231
-----------------------------------------------------
Fax | 814-965-5483
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 516 MARKET ST
-----------------------------------------------------
City | JOHNSONBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15845-1240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-965-3231
-----------------------------------------------------
Fax | 814-965-5483
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/OWNER
-----------------------------------------------------
Name | DR. MARY REED DACANAL
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 814-965-3231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OEG000721
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------