=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548265705
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED EYECARE OF MADISON, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2005
-----------------------------------------------------
Last Update Date | 03/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 INTERCOM DRIVE
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35758-2638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-772-2929
-----------------------------------------------------
Fax | 256-772-2928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 INTERCOM DRIVE
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35758-2638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-772-2929
-----------------------------------------------------
Fax | 256-772-2928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/PRESIDENT
-----------------------------------------------------
Name | DR. AMY SANDERSON
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 256-772-2929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------