=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083073324
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SENIOR VISION CARE, OD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2016
-----------------------------------------------------
Last Update Date | 02/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12612 DIAMOND DR
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28134-8114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-229-0707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12612 DIAMOND DR
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28134-8114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-229-0707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK GIFFORD
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 980-229-0707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2112
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------