=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306034517
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLADYS C MILLS OD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2007
-----------------------------------------------------
Last Update Date | 04/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6703 B NW LOOP 410
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78238-4504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-681-1125
-----------------------------------------------------
Fax | 210-681-1148
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6703 B NW LOOP 410
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-681-1125
-----------------------------------------------------
Fax | 210-681-1148
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, OPTOMETRIST
-----------------------------------------------------
Name | DR. GLADYS C MILLS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 210-681-1125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 5260T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------