=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053580878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BORDASH FAMILY EYE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2008
-----------------------------------------------------
Last Update Date | 08/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 HAMILTON PLACE BLVD STE 280
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-899-8626
-----------------------------------------------------
Fax | 423-855-0044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 HAMILTON PLACE BLVD STE 280
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37421-6030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-899-8626
-----------------------------------------------------
Fax | 423-855-0044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. MICHAEL PAUL BORDASH
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 423-899-8626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1693
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------