=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346459500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | B J RUST JR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 11/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4825 CAMP BOWIE BLVD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76107-4150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-731-4646
-----------------------------------------------------
Fax | 817-731-4646
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4825 CAMP BOWIE BLVD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76107-4150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-731-4646
-----------------------------------------------------
Fax | 817-731-4646
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN
-----------------------------------------------------
Name | MR. B. J. RUST JR.
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 817-338-1121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | DR0128
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------