=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861797482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BIRD ROAD OPTICAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2011
-----------------------------------------------------
Last Update Date | 12/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8485 SW 40TH ST SUITE 103
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-3244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-223-6142
-----------------------------------------------------
Fax | 305-552-0824
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8485 SW 40TH ST SUITE 103
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-3244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-223-6142
-----------------------------------------------------
Fax | 305-552-0824
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DORA REYES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-223-6142
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | OE879
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------