=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770794406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYECARE OPTIQUES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 07/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 S POPLAR ST
-----------------------------------------------------
City | BUCYRUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44820-2663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-562-3822
-----------------------------------------------------
Fax | 419-562-9939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 905 S POPLAR ST
-----------------------------------------------------
City | BUCYRUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44820-2663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-562-3822
-----------------------------------------------------
Fax | 419-562-9939
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WAYNE H COLLIER
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 419-562-3822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2786
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------