=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144415274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYEDEAS UNLIMITED INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2007
-----------------------------------------------------
Last Update Date | 12/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2571 SPRINGS RD NE
-----------------------------------------------------
City | HICKORY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28601-3169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-256-6620
-----------------------------------------------------
Fax | 828-256-4970
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2571 SPRINGS RD NE
-----------------------------------------------------
City | HICKORY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28601-3169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-256-6620
-----------------------------------------------------
Fax | 828-256-4970
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN
-----------------------------------------------------
Name | MRS. DIANE WHITE MAYNARD
-----------------------------------------------------
Credential | NC LICENSED OPTICIAN
-----------------------------------------------------
Telephone | 828-256-6620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 581
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------