=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558675702
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE EYE INSTITUTE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2010
-----------------------------------------------------
Last Update Date | 07/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2631 FOOTHILL BLVD STE A
-----------------------------------------------------
City | ROCK SPRINGS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82901-4770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-362-4202
-----------------------------------------------------
Fax | 307-362-4332
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2631 FOOTHILL BLVD STE A
-----------------------------------------------------
City | ROCK SPRINGS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82901-4770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-362-4202
-----------------------------------------------------
Fax | 307-362-4332
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | RANDY L FUJA
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 307-362-4202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 214T
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------