=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063851822
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TITUS SNELL ABOC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2013
-----------------------------------------------------
Last Update Date | 06/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1604 BEVERLY DR
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39056-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-260-1292
-----------------------------------------------------
Fax | 601-510-9191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 923
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39060-0923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-260-1292
-----------------------------------------------------
Fax | 601-510-9191
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FC0800X
-----------------------------------------------------
Taxonomy Name | Contact Lens Technician/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------