=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558545582
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GORMAN OPTICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2007
-----------------------------------------------------
Last Update Date | 12/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2797 HAMLINE AVE NO HAMLINE CENTER SUITE 2
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113-1715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-639-8227
-----------------------------------------------------
Fax | 651-633-7010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2797 HAMLINE AVE NO HAMLINE CENTER SUITE 2
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113-1715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-639-8227
-----------------------------------------------------
Fax | 651-633-7010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER CERTIFIED OPTICIAN
-----------------------------------------------------
Name | JOAN MARIE GORMAN MEYER
-----------------------------------------------------
Credential | ABOC
-----------------------------------------------------
Telephone | 651-639-8227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 072582
-----------------------------------------------------
License Number State |
-----------------------------------------------------