Basic Information
| Provider Information | |||||||||
| NPI: | 1255490041 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYECARE ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207243 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753207255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270766 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 HIGHWAY 78 E | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 355013957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 2052217578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2006 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | ROQUEMORE | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMESTRIST | ||||||||
| AuthorizedOfficialTelephone: | 2052216718 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | S438TA078 | AL | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 529702030 | 05 | AL | MEDICAID | 1255490041 | 01 | AL | GROUP NPI | OTHER | 1013905637 | 01 | AL | INDIVIDUAL MPI | OTHER |