Basic Information
| Provider Information | |||||||||
| NPI: | 1427166776 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEJEAN & KUGLEN EYE ASSOCIATES LLP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AVERY OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 400 S LOOP 336 W | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773043302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365394500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 S LOOP 336 W | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773043302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365394500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VILLEGAS | ||||||||
| AuthorizedOfficialFirstName: | SHIRIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9365394500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEJEAN & KUGLEN EYE ASSOCIATES LLP | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1264720001 | 01 | TX | D'MERC | OTHER | 079598101 | 05 | TX | MEDICAID | 1427166776 | 01 | TX | NPI | OTHER | 1264720001 | 01 | TX | MEDICARE NSC | OTHER |