Basic Information
| Provider Information | |||||||||
| NPI: | 1851762272 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARK FOREST EYE CARE, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FIRST EYE CARE PARK FOREST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11888 MARSH LN STE 414 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752348083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722418084 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11888 MARSH LN | ||||||||
| Address2: | SUITE 414 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752348083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729602020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2015 | ||||||||
| LastUpdateDate: | 02/01/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOURQUE-WIMBISH | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9722418084 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5376TG | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.