=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972661882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TECUMSEH EYE CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 11/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 E WASHINGTON ST
-----------------------------------------------------
City | TECUMSEH
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74873-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-598-6558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 E WASHINGTON ST
-----------------------------------------------------
City | TECUMSEH
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74873-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-598-6558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JESSICA OZMENT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-598-6558
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2368
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------