=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346525763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER LIN OD A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2011
-----------------------------------------------------
Last Update Date | 10/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 THROCKMORTON AVE
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94941-1918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-383-4085
-----------------------------------------------------
Fax | 415-634-1364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 THROCKMORTON AVE
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94941-1918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-383-4085
-----------------------------------------------------
Fax | 415-634-1364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGING DOCTOR
-----------------------------------------------------
Name | JENNIFER LIN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 916-501-2821
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 13969
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------