=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982740379
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTICS TOWN & COUNTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 07/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 641 EVERHART
-----------------------------------------------------
City | CORPUS CHRISTI
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-854-5088
-----------------------------------------------------
Fax | 361-854-5088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 641 EVERHART
-----------------------------------------------------
City | CORPUS CHRISTI
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-854-5088
-----------------------------------------------------
Fax | 361-854-5088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BENJAMIN L FOSSETT
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 361-854-5088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------