=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700136041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | W-J OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2012
-----------------------------------------------------
Last Update Date | 09/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 BROADWAY AVE
-----------------------------------------------------
City | YANKTON
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57078-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-665-6181
-----------------------------------------------------
Fax | 605-665-6181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 BROADWAY AVE
-----------------------------------------------------
City | YANKTON
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57078-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-665-6181
-----------------------------------------------------
Fax | 605-665-6181
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. WILLIAM KINGSLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-660-3687
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------