=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437433430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WU FAMILY EYE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2011
-----------------------------------------------------
Last Update Date | 10/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 KNOX AVE
-----------------------------------------------------
City | NORTH AUGUSTA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29841-4056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-279-0188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 775 LOCKS WAY
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30907-4975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-364-7863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. YAN WU
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 803-279-0188
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1341
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------