=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881032373
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUSION HD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2013
-----------------------------------------------------
Last Update Date | 06/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3001 WHITE BEAR AVE N SUITE 1050
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55109-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-770-3923
-----------------------------------------------------
Fax | 651-770-5316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 WHITE BEAR AVE N SUITE 1050
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55109-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-770-3923
-----------------------------------------------------
Fax | 651-770-5316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. WENDY SEYLLER PASSMORE
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 651-249-6537
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2105
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------