=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013169044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCANDREW'S EYE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2008
-----------------------------------------------------
Last Update Date | 10/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 N MARIENFELD ST
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79701-3360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-699-4827
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 N MARIENFELD ST
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79701-3360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-699-4827
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL S. MCANDREW
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 432-699-4827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 5302TG OPTOMETRY
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------