=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225146079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAL 4 EYES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 03/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7150 W INTERSTATE 40
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-355-4407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7150 W INTERSTATE 40
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-355-4407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | JAMES A. FITCH
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 806-355-4407
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 1207180001
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------