=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780845610
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANNA M GERVAIS O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2008
-----------------------------------------------------
Last Update Date | 06/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1871 2ND ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97477-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-741-0122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 939 ODOM LN
-----------------------------------------------------
City | CRESWELL
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97426-7506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3263AT
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------