=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124049010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRO OPTICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2006
-----------------------------------------------------
Last Update Date | 07/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5718 MCARDLE RD STE 103
-----------------------------------------------------
City | CORPUS CHRISTI
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78412-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-994-0776
-----------------------------------------------------
Fax | 361-994-0458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5718 MCARDLE RD STE 103
-----------------------------------------------------
City | CORPUS CHRISTI
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78412-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-994-0776
-----------------------------------------------------
Fax | 361-994-0458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICAN
-----------------------------------------------------
Name | MR. MICHAEL PRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 361-994-0776
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 42144
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------