=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871619973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY EYE ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 04/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3700 HILBORN RD STE 500
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94534-7946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-426-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3700 HILBORN RD STE 500
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94534-7946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-426-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER OPTOMETRIST
-----------------------------------------------------
Name | DR. KATHERINE M SEVERIN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 707-426-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | OPT8122TPA
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------