=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922001445
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIM P KRET OD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2005
-----------------------------------------------------
Last Update Date | 11/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3963 BOAT CLUB ROAD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-237-7153
-----------------------------------------------------
Fax | 817-237-7123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3963 BOAT CLUB ROAD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-237-7153
-----------------------------------------------------
Fax | 817-237-7123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TIM P KRET
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 817-237-7153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2288TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------