=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700071883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANBURY EYE CARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2007
-----------------------------------------------------
Last Update Date | 02/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 WATERS EDGE DR STE 104
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048-1474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-579-7933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 WATERS EDGE DR STE 104
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048-1474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-579-7933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. BRUCE B WADLEY
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 817-579-7933
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 5503TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------