=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780959726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAZZARY EYE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2012
-----------------------------------------------------
Last Update Date | 03/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 N FRANKLIN ST
-----------------------------------------------------
City | WATKINS GLEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14891-1252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-499-9131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 COUNTY ROAD 17
-----------------------------------------------------
City | WATKINS GLEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14891-9401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-499-9131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ASHLEY B FAZZARY
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 917-499-9131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 007410
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------