=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366620734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKER OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2008
-----------------------------------------------------
Last Update Date | 02/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1317 S JOSHUA AVE # H
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85344-5754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-669-6971
-----------------------------------------------------
Fax | 928-669-8901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1317 S JOSHUA AVE # H
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85344-5754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-669-6971
-----------------------------------------------------
Fax | 928-669-8901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DENNIS INGRAM
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 928-669-6971
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 721
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------