=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679032288
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAMPSTEAD OPTOMETRY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16747 US HIGHWAY 17 N STE 140
-----------------------------------------------------
City | HAMPSTEAD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28443-3695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-495-0031
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 DRAKE RD
-----------------------------------------------------
City | HAMPSTEAD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28443-2550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-495-0031
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LORI FARABAUGH
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 856-495-0031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------