=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457300683
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE SPECIALIST INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2006
-----------------------------------------------------
Last Update Date | 09/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 WEST EMMITT AVENUE SUITE 4
-----------------------------------------------------
City | WAVERLY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45690-1084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-941-3937
-----------------------------------------------------
Fax | 740-941-3786
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 N PLAZA BLVD
-----------------------------------------------------
City | CHILLICOTHEE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45601-1757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-587-8790
-----------------------------------------------------
Fax | 740-774-4061
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CENTER DIRECTOR
-----------------------------------------------------
Name | TERRY SHULTZ
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 800-948-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------