=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750654265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERIM EYECARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2012
-----------------------------------------------------
Last Update Date | 02/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1429 GOOD HOPE ROAD, SE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-245-4022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4812 SILVERBROOK WAY
-----------------------------------------------------
City | BOWIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-254-0487
-----------------------------------------------------
Fax | 240-245-4022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. DOMINIC SUNDAY ONWUKWE
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 301-254-0487
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OP 1000092
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------