=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013187178
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACK DEVORE, OD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2008
-----------------------------------------------------
Last Update Date | 09/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 NORMANSKILL BLVD
-----------------------------------------------------
City | DELMAR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12054-1335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-478-9992
-----------------------------------------------------
Fax | 518-439-0796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 NORMANSKILL BLVD
-----------------------------------------------------
City | DELMAR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12054-1335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-478-9992
-----------------------------------------------------
Fax | 518-439-0796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JACK DEVORE
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 518-478-9992
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | VUT003734
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------