=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770893729
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MORICHES VISION CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2010
-----------------------------------------------------
Last Update Date | 10/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 MONTAUK HWY SUITE 106
-----------------------------------------------------
City | MORICHES
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-878-0606
-----------------------------------------------------
Fax | 631-909-4325
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 MONTAUK HWY SUITE 106
-----------------------------------------------------
City | MORICHES
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-878-0606
-----------------------------------------------------
Fax | 631-909-4325
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN/PRESIDENT
-----------------------------------------------------
Name | JEREMY BECK
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 631-878-0606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 8025-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------