=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225120660
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON I GIM O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9115 S TACOMA WAY #106
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-588-4225
-----------------------------------------------------
Fax | 253-588-4402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9115 S TACOMA WAY #106
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-588-4225
-----------------------------------------------------
Fax | 253-588-4402
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WL0500X
-----------------------------------------------------
Taxonomy Name | Low Vision Rehabilitation Optometrist
-----------------------------------------------------
License Number | 3284
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------