=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144602442
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE EYE STUDIO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2015
-----------------------------------------------------
Last Update Date | 06/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 508 BROADWAY STE 2
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12701-1105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-796-2020
-----------------------------------------------------
Fax | 845-794-7441
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 468
-----------------------------------------------------
City | ELLENVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12428-0468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-796-2020
-----------------------------------------------------
Fax | 845-796-7441
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LINA MARIA ESCOBAR
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 845-796-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0059141
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------