=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528351566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTICAL BROKERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2011
-----------------------------------------------------
Last Update Date | 05/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 NW 21ST AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97209-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-295-6488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 134 NW 21ST AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97209-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-295-6488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEBBRA KAY SUMMERS
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 503-295-6488
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 156FX1100X
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------