=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447441050
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POWELL OPTOMETRY A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2007
-----------------------------------------------------
Last Update Date | 12/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2320 S MAIN ST
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64468-3622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-582-4022
-----------------------------------------------------
Fax | 660-582-4038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2320 S MAIN ST
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64468-3622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-582-4022
-----------------------------------------------------
Fax | 660-582-4038
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFREY HAIDON POWELL
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 660-582-4022
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2002015841
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TO2187
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------