=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043407927
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALSH OPTOMETRY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2007
-----------------------------------------------------
Last Update Date | 11/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7330 OLD WAKE FOREST RD.
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27616-3047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-792-2999
-----------------------------------------------------
Fax | 919-554-1406
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 80214
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27623-0214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-792-2999
-----------------------------------------------------
Fax | 919-554-1406
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/PRESIDENT
-----------------------------------------------------
Name | DR. EILEEN MARIE WALSH
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 919-844-0938
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1630
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------