=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487832556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED MOBILE EYE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2008
-----------------------------------------------------
Last Update Date | 08/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2810 NILES RD
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-429-6781
-----------------------------------------------------
Fax | 269-429-5006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2810 NILES RD
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-429-6781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFREY FRED SCIESZKA
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 269-369-6752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901003732
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------