=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063587590
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISION SOURCE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 09/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5590 CHALKVILLE RD STE B
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35235-8637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-520-9002
-----------------------------------------------------
Fax | 205-520-9064
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5590 CHALKVILLE RD SUITE B
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35235-8636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-520-9002
-----------------------------------------------------
Fax | 205-520-9064
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GARY C FEW
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 205-520-9002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 07005076
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------