=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407186844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BARRY S GREEN O.D. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2010
-----------------------------------------------------
Last Update Date | 01/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7147 BURNETT ST
-----------------------------------------------------
City | SEBASTOPOL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95472-4349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-829-5440
-----------------------------------------------------
Fax | 888-416-4393
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7147 BURNETT ST
-----------------------------------------------------
City | SEBASTOPOL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95472-4349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-829-5440
-----------------------------------------------------
Fax | 888-416-4393
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/PRESIDENT
-----------------------------------------------------
Name | DR. BARRY SETH GREEN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 707-829-5440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 9001T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------