=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962820050
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PVBLUFFTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2014
-----------------------------------------------------
Last Update Date | 04/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 MALPHRUS RD STE 101
-----------------------------------------------------
City | BLUFFTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29910-6635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-837-9222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 MALPHRUS RD STE 101
-----------------------------------------------------
City | BLUFFTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29910-6635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-837-9222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NICHOLAS BOLLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-382-2542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 15029
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------