=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609984673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TUSCALOOSA OPTICAL DISPENSARY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 06/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5121 UNIVERSITY BLVD E
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35404-5207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-562-8177
-----------------------------------------------------
Fax | 205-554-7968
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5121 UNIVERSITY BLVD E
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35404-5207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-562-8177
-----------------------------------------------------
Fax | 205-554-7968
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILLIAM DAVID ANDERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-562-8177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 3693
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------