=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407290646
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMOND AGRESTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2013
-----------------------------------------------------
Last Update Date | 04/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 153 N 4TH ST
-----------------------------------------------------
City | STEUBENVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43952-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-283-2461
-----------------------------------------------------
Fax | 740-283-2303
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 153 N 4TH ST
-----------------------------------------------------
City | STEUBENVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43952-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-283-2461
-----------------------------------------------------
Fax | 740-283-2303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | SC5207
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------