=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356697213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JI EYE CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2012
-----------------------------------------------------
Last Update Date | 07/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2034 CENTRE ST A
-----------------------------------------------------
City | WEST ROXBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02132-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-469-8733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2034 CENTRE ST A
-----------------------------------------------------
City | WEST ROXBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-469-8733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | HONG JI
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 617-469-8733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4886
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------