Basic Information
| Provider Information | |||||||||
| NPI: | 1396221685 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHLAKE FAMILY EYECARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9816 N BEACH ST | ||||||||
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| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762446184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177412020 | ||||||||
| FaxNumber: | 8177413937 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 COMMONS CIRCLE STE. 200 | ||||||||
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| City: | NORTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177412020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2018 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | NURSS | ||||||||
| AuthorizedOfficialFirstName: | DORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | INSURANCE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8177412020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.