=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700113263
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM B HIRSHOM OPTICIAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2009
-----------------------------------------------------
Last Update Date | 11/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 380 SOUTH ST RIGHT WALKWAY
-----------------------------------------------------
City | HYANNIS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-771-3889
-----------------------------------------------------
Fax | 508-771-3889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2825 380 SOUTH ST
-----------------------------------------------------
City | HYANNIS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-771-3889
-----------------------------------------------------
Fax | 508-771-3889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 4216(OPTICIAN)
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------