=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063662328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VERRETT VISION ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2008
-----------------------------------------------------
Last Update Date | 09/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1966 NE 123RD ST 128
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33181-2868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-782-4855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1966 NE 123RD ST 128
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33181-2868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-782-4855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | DR. KEELEY W VERRETT
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 504-782-4855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1267-421T
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------