=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134506983
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ONE WORLD OPTICAL BUSINESS L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2015
-----------------------------------------------------
Last Update Date | 05/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105A TRADEWYND DR SUITE 3
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24502-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-382-8207
-----------------------------------------------------
Fax | 434-266-0078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1076 GABLES DR APT 207
-----------------------------------------------------
City | FOREST
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24551-4755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-382-8207
-----------------------------------------------------
Fax | 434-266-0078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ABOC/LICENSED OPTICIAN/OWNER
-----------------------------------------------------
Name | MR. MARTIN SHAHMIRZADI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-382-8207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 1101003537
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 1101003537
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------