=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508178450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREG PIENTKA, O.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2010
-----------------------------------------------------
Last Update Date | 03/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 640 W BOYNTON BEACH BLVD
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33426-3637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-732-8088
-----------------------------------------------------
Fax | 561-732-8112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 640 W BOYNTON BEACH BLVD
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33426-3637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-732-8088
-----------------------------------------------------
Fax | 561-732-8112
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE PRESIDENT
-----------------------------------------------------
Name | DR. GREG PIENTKA
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 561-732-8088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC 3038
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------