Basic Information
Provider Information | |||||||||
NPI: | 1093937856 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOUR GLASS INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE HOUR GLASS INC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1480 TIMBERLANE RD | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323121713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508934687 | ||||||||
FaxNumber: | 8508936098 | ||||||||
Practice Location | |||||||||
Address1: | 1480 TIMBERLANE RD | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323121713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508934687 | ||||||||
FaxNumber: | 8508936098 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2007 | ||||||||
LastUpdateDate: | 01/25/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STEPHENS | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 8508934687 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | OD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 200400209802227 | FL | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
ID Information
ID | Type | State | Issuer | Description | 19604 | 01 | FL | SPECTERA | OTHER |