=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376846519
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL B. FREELAND O.D. INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2010
-----------------------------------------------------
Last Update Date | 08/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4976 VERDUGO WAY
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93012-8632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-482-4628
-----------------------------------------------------
Fax | 805-482-4620
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4976 VERDUGO WAY
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93012-8632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-482-4628
-----------------------------------------------------
Fax | 805-482-4620
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL BRIAN FREELAND
-----------------------------------------------------
Credential | O.D
-----------------------------------------------------
Telephone | 805-482-4628
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------