=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710190756
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRS. DISTIN & DOYLE, OPTOMETRISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 10/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2108 S. E 3D ST
-----------------------------------------------------
City | ALEDO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61231-9456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-582-5673
-----------------------------------------------------
Fax | 309-582-5674
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2108 S. E. THIRD ST
-----------------------------------------------------
City | ALEDO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61231-9456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-582-5673
-----------------------------------------------------
Fax | 309-582-5674
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MARY G DISTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-582-5673
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------