=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043495062
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | T M SWINGER & D V MCKILLIP, PTR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2008
-----------------------------------------------------
Last Update Date | 07/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 KING AVE
-----------------------------------------------------
City | PORTAGEVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63873-1441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-379-5235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 KING AVE
-----------------------------------------------------
City | PORTAGEVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63873-1441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-379-5235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | VICKIE L HURLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-379-5235
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | T02167
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------