=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326206186
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 316 OPTOMETRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2008
-----------------------------------------------------
Last Update Date | 11/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 E CHICAGO ST
-----------------------------------------------------
City | COLDWATER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49036-2055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-278-2809
-----------------------------------------------------
Fax | 517-278-2199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 172 CHURCH ST
-----------------------------------------------------
City | COLDWATER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49036-1756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-268-5140
-----------------------------------------------------
Fax | 517-278-2199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARIA LYN-SHOOP GARCIA
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 269-268-5140
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 4901003648
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------