=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407950041
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY ALVIS SEAL O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2006
-----------------------------------------------------
Last Update Date | 02/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 416 NORTH GRAY ST KILLEEN EYECARE CENTER
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-634-7805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3905 BELLA VISTA LOOP
-----------------------------------------------------
City | HARKER HEIGHTS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76548-8723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-285-6316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2079
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4706TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------