=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770850471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYEGLASS WORLD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2011
-----------------------------------------------------
Last Update Date | 11/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4763 WILSON AVE SW STE G&H
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-9015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-261-4811
-----------------------------------------------------
Fax | 616-261-4831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 296 GRAYSON HWY
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046-5737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-822-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MC ASST
-----------------------------------------------------
Name | SUSAN EDICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-892-3774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------