=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174940142
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHELL POINT FAMILY EYECARE & OPTICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2014
-----------------------------------------------------
Last Update Date | 12/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 MIDTOWN DR
-----------------------------------------------------
City | BEAUFORT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29906-5203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-521-4037
-----------------------------------------------------
Fax | 843-521-0138
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 MIDTOWN DR
-----------------------------------------------------
City | BEAUFORT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29906-5203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-521-4037
-----------------------------------------------------
Fax | 843-521-0138
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. FERINE JOHANNES
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 920-915-3422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1568
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------