=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508533530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IREFRACT PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2021
-----------------------------------------------------
Last Update Date | 08/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 W BLACKSTOCK RD
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29301-1382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-256-3311
-----------------------------------------------------
Fax | 864-256-3322
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8525 E PINNACLE PEAK RD STE 101
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-3581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-791-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPTOMETRIST
-----------------------------------------------------
Name | DREW PROVOST
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 512-934-4444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------