=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114948304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TPB ENTERPRISES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2006
-----------------------------------------------------
Last Update Date | 04/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 545 UNION AVE
-----------------------------------------------------
City | FRAMINGHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01702-5819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-875-9636
-----------------------------------------------------
Fax | 508-875-3770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 545 UNION AVE
-----------------------------------------------------
City | FRAMINGHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01702-5819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-875-9636
-----------------------------------------------------
Fax | 508-875-3770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | TRUNG VAN BUI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 508-875-9636
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4555
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------