=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447550140
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOMETOWN OPTICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2010
-----------------------------------------------------
Last Update Date | 10/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8396 MAYFIELD RD
-----------------------------------------------------
City | CHESTERLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44026-2522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-729-2293
-----------------------------------------------------
Fax | 440-729-2296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8396 MAYFIELD RD
-----------------------------------------------------
City | CHESTERLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44026-2522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-729-2293
-----------------------------------------------------
Fax | 440-729-2296
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MICHAEL JEZEWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 440-729-2293
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 332H00000X
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------