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General NPI Number Information
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NPI Number | 1801112909
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Entity Type | Organization
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Legal Business Name | GENESIS EYECARE
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Dates
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Enumeration Date | 04/14/2010
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Last Update Date | 04/14/2010
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Provider Practice Location Address
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Address Line | 857 GEORGE WASHINGTON HWY N BOX 6855
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City | CHESAPEAKE
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State | VA
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Zip | 23323-2297
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Country | US
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Telephone | 757-558-8439
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Fax |
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Provider Business Mailing Address
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Address Line | 857 GEORGE WASHINGTON HWY N POB 6855
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City | CHESAPEAKE
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State | VA
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Zip | 23323-2297
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | V. SULLIVAN
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Credential |
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Telephone | 757-558-8439
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0618001512
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License Number State | VA
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