=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447797717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIE S JEAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2017
-----------------------------------------------------
Last Update Date | 01/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 MAIN ST
-----------------------------------------------------
City | BEACON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12508-3079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-765-1255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 MAIN ST
-----------------------------------------------------
City | BEACON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12508-3079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-765-1255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIE SYBILLE JEAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-671-4372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------