=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043487515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BASTIN OPTOMETRIC EYE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2008
-----------------------------------------------------
Last Update Date | 06/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1016 S MAIN ST
-----------------------------------------------------
City | HOPKINSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42240-2010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-886-2293
-----------------------------------------------------
Fax | 270-886-0399
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1016 S MAIN ST
-----------------------------------------------------
City | HOPKINSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42240-2010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-886-2293
-----------------------------------------------------
Fax | 270-886-0399
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | ROBERT JOSEPH BASTIN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 270-886-2293
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1164 DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------