=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386740884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACCENT EYE CARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 05/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 E ASH ST
-----------------------------------------------------
City | PERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32347-2105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-584-2200
-----------------------------------------------------
Fax | 850-584-4412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 219 MAGNOLIA RD
-----------------------------------------------------
City | PERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32348-6118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-223-3402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL ANDREW WALBY
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 850-584-2200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OP1063
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------