=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912064023
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RJ BUSCH OPTICAL DESIGNS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 01/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 WOODLAND AVE
-----------------------------------------------------
City | SCHENECTADY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12309-6116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-393-3360
-----------------------------------------------------
Fax | 518-393-1699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 915 WOODLAND AVE
-----------------------------------------------------
City | SCHENECTADY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12309-6116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-393-3360
-----------------------------------------------------
Fax | 518-393-1699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RICHARD J BUSCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 518-393-3360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | C0045271
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------