=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962775817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTSIDE OPTICAL SHOP,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2012
-----------------------------------------------------
Last Update Date | 05/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1413 JOHN B WHITE SR BLVD SUITE A
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29306-3995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-587-1039
-----------------------------------------------------
Fax | 864-587-1936
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1413 JOHN B WHITE SR BLVD SUITE A
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29306-3995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-587-1039
-----------------------------------------------------
Fax | 864-587-1936
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | DR. LAWRENCE EDMUND ROEL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 864-542-1308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 120021119
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------