=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083010888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOORES MILL EYECARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2014
-----------------------------------------------------
Last Update Date | 04/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2415 MOORES MILL RD SUITE 220
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36830-8482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-521-7944
-----------------------------------------------------
Fax | 334-521-7277
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2415 MOORES MILL RD SUITE 220
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36830-8482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-521-7944
-----------------------------------------------------
Fax | 334-521-7277
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DAVID OLIVE
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 334-521-7944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | S931TA494
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------