=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861661175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAURIE S MCCONNELL OD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2008
-----------------------------------------------------
Last Update Date | 07/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 S US HIGHWAY 1
-----------------------------------------------------
City | TEQUESTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33469-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-746-5088
-----------------------------------------------------
Fax | 561-746-5989
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 S US HIGHWAY 1
-----------------------------------------------------
City | TEQUESTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33469-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-746-5088
-----------------------------------------------------
Fax | 561-746-5989
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTOMETRIST
-----------------------------------------------------
Name | DR. LAURIE SEBRING MCCONNELL
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 561-746-5088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OB 2812
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------