=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710108402
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK G. MITCHELL, OD, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 10/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 KIETZKE LN B-119
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89502-5033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-825-0506
-----------------------------------------------------
Fax | 775-825-0873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4600 KIETZKE LN B-119
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89502-5033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-825-0506
-----------------------------------------------------
Fax | 775-825-0873
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. MARK GLENN MITCHELL
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 775-825-0506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 374
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------