Basic Information
| Provider Information | |||||||||
| NPI: | 1023266863 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEHAVEN OPTICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LONESTAR OPTICAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NORTH PACIFIC | ||||||||
| Address2: | |||||||||
| City: | MINEOLA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757731836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035954144 | ||||||||
| FaxNumber: | 9035265491 | ||||||||
| Practice Location | |||||||||
| Address1: | 908 NORTH PACIFIC | ||||||||
| Address2: | |||||||||
| City: | MINEOLA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757731836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035699945 | ||||||||
| FaxNumber: | 9035699974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2008 | ||||||||
| LastUpdateDate: | 04/17/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOWNDES | ||||||||
| AuthorizedOfficialFirstName: | GINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL SERVICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9035957510 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 203580001 | 05 | TX | MEDICAID |