=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265402911
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUSTIN M HATCH O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2006
-----------------------------------------------------
Last Update Date | 03/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 526 SHOUP AVE W STE H
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-733-2400
-----------------------------------------------------
Fax | 208-734-0343
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 526 SHOUP AVE W STE H
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-733-2400
-----------------------------------------------------
Fax | 208-734-0343
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODP-100048
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------