=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164563938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C & S OPTOMETRIC SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13820 HWY 55 E.
-----------------------------------------------------
City | ALLIANCE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-745-4100
-----------------------------------------------------
Fax | 252-745-3909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 219
-----------------------------------------------------
City | ALLIANCE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28509-0219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-745-4100
-----------------------------------------------------
Fax | 252-745-3909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING CO-OWNER
-----------------------------------------------------
Name | SHAWN A DOTY
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 252-745-4100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------