=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629176581
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAYLE DEAN BOATWRIGHT O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1095 INDUSTRIAL PKWY
-----------------------------------------------------
City | SARALAND
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36571-3719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-675-0841
-----------------------------------------------------
Fax | 251-679-4109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15031 TIMBER RIDGE DR
-----------------------------------------------------
City | LOXLEY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36551-5413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-964-4629
-----------------------------------------------------
Fax | 251-679-4109
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | S884T442
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------