=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770195794
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAITLIN ELISE-NOSANOV WINSOR OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2020
-----------------------------------------------------
Last Update Date | 08/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1761 W M 43 HWY STE 1
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49058-8567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-945-3888
-----------------------------------------------------
Fax | 269-945-2112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1761 W M 43 HWY STE 1
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49058-8567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-945-3888
-----------------------------------------------------
Fax | 269-945-2112
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901005458
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------