=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033586912
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COURTNEY ELIZABETH JUSTICE O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2015
-----------------------------------------------------
Last Update Date | 08/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 BETHEL RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43220-2217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-326-0761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 308 ELIZABETH LN
-----------------------------------------------------
City | WAVERLY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45690-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-222-8794
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT.6382
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------