=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285751552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEYER OPTICAL CO. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2007
-----------------------------------------------------
Last Update Date | 06/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 W RIVER ST
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-1964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-939-2222
-----------------------------------------------------
Fax | 815-939-0970
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 135 W RIVER ST
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-1964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-939-2222
-----------------------------------------------------
Fax | 815-939-0970
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. MARK JOHN VIDAS
-----------------------------------------------------
Credential | 0.D.
-----------------------------------------------------
Telephone | 815-939-2222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------