=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306901772
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBORAH WITT CHURCH OPTICIAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 COMMONWEALTH BLVD W
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24112-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-638-4461
-----------------------------------------------------
Fax | 276-638-1859
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 WITTS LN
-----------------------------------------------------
City | BASSETT
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24055-8013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-629-5588
-----------------------------------------------------
Fax | 276-638-1859
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 1101001459
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------