=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902862717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEISS EYE CARE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2006
-----------------------------------------------------
Last Update Date | 01/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 19TH ST NE
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57201-6799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-882-0808
-----------------------------------------------------
Fax | 605-882-7078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 19TH ST NE
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57201-6799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-882-0808
-----------------------------------------------------
Fax | 605-882-7078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER /OPTOMETRIST
-----------------------------------------------------
Name | DR. MELANIE D WEISS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 605-882-0808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | SDT555
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------