=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548549272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE EYE SHOP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2011
-----------------------------------------------------
Last Update Date | 08/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1904 2ND AVE E
-----------------------------------------------------
City | ONEONTA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35121-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-274-4433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1904 2ND AVE E
-----------------------------------------------------
City | ONEONTA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35121-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-274-4433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ASHLEY BRETT FOX
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 205-612-1941
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | S-C57-TA-887
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------