=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922274661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLANKENSHIP & DAVIS OPTICIANS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2008
-----------------------------------------------------
Last Update Date | 10/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 WEST MAIN STREET
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-792-0770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 WEST MAIN STREET
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-792-0770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OWNER
-----------------------------------------------------
Name | MICHAEL BURGESS CUMBIE
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 434-792-0770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 1101000945
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------