=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669532297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYESWEST OPTICAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 04/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12801 W BELL RD SUITE 139
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85378-9797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-583-0377
-----------------------------------------------------
Fax | 623-583-0378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12801 W BELL RD SUITE 139
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85378-9797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-583-0377
-----------------------------------------------------
Fax | 623-583-0378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. SCOTT A FINEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-583-0377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 627
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------