=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790230977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREGORY EYE ENTERPRISE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2016
-----------------------------------------------------
Last Update Date | 08/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4606 HIGHWAY 280 STE 116
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242-8127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-919-4008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2008 3RD AVE N APT 2B
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35203-3399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CAITLIN GREGORY
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 205-919-4008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | SD62TAA48
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------