=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164956330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEAN CLAUDE ST. GERMAIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2017
-----------------------------------------------------
Last Update Date | 04/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 49 N 52ND ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19139-2644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-472-2550
-----------------------------------------------------
Fax | 215-472-2551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49 N 52ND ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19139-2644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-472-2550
-----------------------------------------------------
Fax | 215-472-2551
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEAN-CLAUDE ST. GERMAIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-472-2550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FC0800X
-----------------------------------------------------
Taxonomy Name | Contact Lens Technician/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------