=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073642054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN OPTICAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2007
-----------------------------------------------------
Last Update Date | 02/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2648 LEE AVE
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27332-5950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-775-5221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2648 LEE AVE
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27332-5950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-775-5221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ROGER DWIGHT THOMAS SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-775-5221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 0710
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------