=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922200096
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE STREET OPTICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2007
-----------------------------------------------------
Last Update Date | 10/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3910 CENTREVILLE RD SUITE 100
-----------------------------------------------------
City | CHANTILLY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20151-3279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-830-6377
-----------------------------------------------------
Fax | 703-263-0326
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3910 CENTREVILLE RD SUITE 100
-----------------------------------------------------
City | CHANTILLY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20151-3279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-830-6377
-----------------------------------------------------
Fax | 703-263-0326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN OWNER
-----------------------------------------------------
Name | KATHRYN BERG FRITZKE
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 703-830-6377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 1101 000766
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------