=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649562794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAZ EYECARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2011
-----------------------------------------------------
Last Update Date | 05/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19752 NORTH FWY STE B
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77373-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-594-7156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19752 NORTH FWY STE B
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77373-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-594-7156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPEUTIC OPTOMETRIST/ OWNER
-----------------------------------------------------
Name | DR. ALNAZ FAZLALIZADEH
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 832-594-7156
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 7443TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------