=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841711082
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE KIM OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2017
-----------------------------------------------------
Last Update Date | 06/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 MELBOURNE RD STE 3002
-----------------------------------------------------
City | HURST
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76053-6225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-284-0798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1404 INDIAN SPGS
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75007-6000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 9172T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------