=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053597336
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANIEL COWLING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2008
-----------------------------------------------------
Last Update Date | 01/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 495 N COURTENAY PKWY
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32953-3485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-454-3100
-----------------------------------------------------
Fax | 321-453-1365
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 495 N COURTENAY PKWY
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32953-3485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-454-3100
-----------------------------------------------------
Fax | 321-453-1365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JULIE MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-454-3100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC2267
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------