=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417945775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTON EYE ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2005
-----------------------------------------------------
Last Update Date | 08/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2325 ABERDEEN BLVD STE A
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28054-0614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-853-3937
-----------------------------------------------------
Fax | 704-853-0840
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2325 ABERDEEN BLVD STE A
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28054-0614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-853-3937
-----------------------------------------------------
Fax | 704-853-0840
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | DR. BOB MCCULLEN JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 704-853-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------