=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083850606
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOONE TRAIL OPTOMETRIC EYE CARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2009
-----------------------------------------------------
Last Update Date | 01/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48 BOONE TRL
-----------------------------------------------------
City | NORTH WILKESBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28659-3515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-667-3288
-----------------------------------------------------
Fax | 336-838-1092
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 48 BOONE TRL
-----------------------------------------------------
City | NORTH WILKESBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28659-3515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-667-3288
-----------------------------------------------------
Fax | 336-838-1092
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SANDRA LOVE SWARINGEN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 336-667-3288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1062
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------