=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649338435
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIRX INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2006
-----------------------------------------------------
Last Update Date | 06/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7178 WEST BLVD SUITE D
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-758-9759
-----------------------------------------------------
Fax | 330-729-0742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7178 WEST BLVD SUITE D
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-758-9759
-----------------------------------------------------
Fax | 330-729-0742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. KEVIN R BURNS
-----------------------------------------------------
Credential | LDO
-----------------------------------------------------
Telephone | 330-758-9759
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1847SC
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------