=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477578458
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK ALAN JURY OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23905 CLINTON KEITH RD SUITE115
-----------------------------------------------------
City | WILDOMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92595-7897
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-304-9733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39708 NICE AVE
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92562-6704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-600-9844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 9583T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------