=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750081980
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA BUSCH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2023
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 804 PIKE STREET VISION CENTER
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-376-0161
-----------------------------------------------------
Fax | 740-376-0164
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 PIKE STREET VISION CENTER
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-376-0161
-----------------------------------------------------
Fax | 740-376-0164
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | OP.007532-SC
-----------------------------------------------------
License Number State |
-----------------------------------------------------