=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164668802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOMETOWN OPTICAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2008
-----------------------------------------------------
Last Update Date | 12/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13244 US HIGHWAY 1
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-3750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-388-0308
-----------------------------------------------------
Fax | 772-228-9111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13244 US HIGHWAY 1
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-3750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-388-0308
-----------------------------------------------------
Fax | 772-228-9111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OPTICIAN
-----------------------------------------------------
Name | MR. NATHAN SHANE STYRON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-388-0308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | DO4689
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------