=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841460722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 20 20 OPTICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2008
-----------------------------------------------------
Last Update Date | 12/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 19TH ST N
-----------------------------------------------------
City | BESSEMER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35020-4821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-424-2020
-----------------------------------------------------
Fax | 205-425-5665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 19TH ST N
-----------------------------------------------------
City | BESSEMER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35020-4821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-424-2020
-----------------------------------------------------
Fax | 205-425-5665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JAKE CLINTON GOODWIN
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 205-424-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 08007709
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------