=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144535949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. MACIEJ Z. KOWALSKI, O.D. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2010
-----------------------------------------------------
Last Update Date | 09/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26672 MARGARITA RD SUITE 305
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92563-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-894-1515
-----------------------------------------------------
Fax | 951-894-1544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28656 BAR HARBOR LN
-----------------------------------------------------
City | TEMECULA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92591-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-551-6531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/OWNER
-----------------------------------------------------
Name | DR. MACIEJ KOWALSKI
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 951-551-6531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 12596T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------