=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811770258
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPITOL EYES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2023
-----------------------------------------------------
Last Update Date | 08/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 W BROAD ST STE 231
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43215-5937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-224-8005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8180 N LONGVIEW HTS
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45701-9610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-856-2957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER / OWNER
-----------------------------------------------------
Name | DR. SHANE FOSTER
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 740-856-2957
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------