=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275730525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TYSONS CORNER OPTICIANS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2007
-----------------------------------------------------
Last Update Date | 08/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8150 LEESBURG PIKE SUITE 901
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-7715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-790-0803
-----------------------------------------------------
Fax | 703-356-5639
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8150 LEESBURG PIKE SUITE 901
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-7750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-790-0803
-----------------------------------------------------
Fax | 703-356-5639
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CARL LETO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 703-790-0803
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 1101001692
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------