=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184877318
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONTACT FILL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2008
-----------------------------------------------------
Last Update Date | 10/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5040 RITTER RD
-----------------------------------------------------
City | MECHANICSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17055-4879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-458-9116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5040 RITTER RD
-----------------------------------------------------
City | MECHANICSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17055-4879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-458-9116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. STEVEN NICOLETOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-574-2400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | N/A
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------