=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760658702
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE EYEGLASS PLACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2008
-----------------------------------------------------
Last Update Date | 04/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 544 E STUART DR
-----------------------------------------------------
City | GALAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24333-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-236-4066
-----------------------------------------------------
Fax | 276-236-4066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 904
-----------------------------------------------------
City | GALAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24333-0904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-236-4066
-----------------------------------------------------
Fax | 276-236-4066
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTICIAN
-----------------------------------------------------
Name | MARY MARGARET RECTOR
-----------------------------------------------------
Credential | R.O.
-----------------------------------------------------
Telephone | 276-236-4066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 1101001399
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------