=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598044182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATSIRT PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2011
-----------------------------------------------------
Last Update Date | 08/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6640 CYPRESSWOOD DR SUITE 105
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77379-7737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-355-9090
-----------------------------------------------------
Fax | 281-602-8419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6640 CYPRESSWOOD DR SUITE 105
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77379-7737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-355-9090
-----------------------------------------------------
Fax | 281-602-8419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. CROSBY W WALLACE
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 281-355-9090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 5527TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------