=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487044129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALBERT R DUCHARME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2015
-----------------------------------------------------
Last Update Date | 02/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1320 SHELFER ST
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34748-3929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-728-1700
-----------------------------------------------------
Fax | 352-728-0057
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1320 SHELFER ST
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34748-3929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-728-1700
-----------------------------------------------------
Fax | 352-728-0057
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. SHANNON MARIE LEAFERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-728-1700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC1146
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------