=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386174837
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYEWORKS OPTOMETRY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2017
-----------------------------------------------------
Last Update Date | 06/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7407 MELROSE AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046-7514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-653-8255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 ELLIOT LN
-----------------------------------------------------
City | COTO DE CAZA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92679-5155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-841-6549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARLA ECK
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 630-841-6549
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------