Basic Information
| Provider Information | |||||||||
| NPI: | 1699811828 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYEGLASS WORLD, LLC 75 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3801 S CONGRESS AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334614140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619659110 | ||||||||
| FaxNumber: | 5616424063 | ||||||||
| Practice Location | |||||||||
| Address1: | 2533 N 75TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850351211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232472706 | ||||||||
| FaxNumber: | 6232471315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | BEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5619659110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 03011217 | AZ | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.