=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932256583
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREEDOM LASER, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 08/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2743 MOUNT PLEASANT ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52601-2137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-758-1107
-----------------------------------------------------
Fax | 319-758-6241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2743 MOUNT PLEASANT ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52601-2137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-758-1107
-----------------------------------------------------
Fax | 319-758-6241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KEVIN TODD JENNINGS
-----------------------------------------------------
Credential | O.D
-----------------------------------------------------
Telephone | 319-758-1107
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 152W00000X
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------