=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013300581
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPORTY SPEX
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2015
-----------------------------------------------------
Last Update Date | 03/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 740 HOOSICK RD
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12180-6679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-328-8364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 740 HOOSICK RD
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12180-6679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-328-8364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN
-----------------------------------------------------
Name | KEVIN WALKER
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 518-328-8364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 005468-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------