=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891335709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAILE OPTOMETRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2020
-----------------------------------------------------
Last Update Date | 01/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 863 HARVEST LN
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05495-7319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-878-2633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 MULBERRY LN UNIT 304
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05401-5899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | FERNANDO ELIAS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 305-799-2723
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------