=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184897993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARRON, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2008
-----------------------------------------------------
Last Update Date | 12/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 49 MORTON AVE
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23805-2751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-732-2020
-----------------------------------------------------
Fax | 804-732-0470
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49 MORTON AVE
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23805-2751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-732-2020
-----------------------------------------------------
Fax | 804-732-0470
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. DOROTHY VERNELL FREEMAN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 804-732-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 0618000457
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0618000457
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------