=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790978831
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISION MAX PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2007
-----------------------------------------------------
Last Update Date | 03/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1323 SPRING ST
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-8720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-439-3937
-----------------------------------------------------
Fax | 231-439-9058
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1323 SPRING ST
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-8720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-439-3937
-----------------------------------------------------
Fax | 231-439-9058
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MAX H. ENGELMAN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 231-439-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2958
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------