=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770777914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. ROBERT BASTAICH & ASSOC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2007
-----------------------------------------------------
Last Update Date | 08/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 SHEILA LN
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23225-2041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-320-9457
-----------------------------------------------------
Fax | 804-320-9458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 SHEILA LN
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23225-2041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-320-9457
-----------------------------------------------------
Fax | 804-320-9458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. ROBERT BASTAICH
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 804-320-9457
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0618001635
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------