=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295884898
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR THOMAS E UNTERBRINK OD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 07/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2202 DANIEL CREEK RD
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24078-1370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-647-3861
-----------------------------------------------------
Fax | 276-647-4217
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2202 DANIEL CREEK RD
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24078-1370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-647-3861
-----------------------------------------------------
Fax | 276-647-4217
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THOMAS EDWARD UNTERBRINK
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 276-647-3861
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0618000365
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------