Provider Demographics
NPI:1073240271
Name:20/20 ICARE TYLER PLLC
Entity Type:Organization
Organization Name:20/20 ICARE TYLER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LONG
Authorized Official - Middle Name:
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-262-2145
Mailing Address - Street 1:5836 SUNNY MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8782
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4824 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1312
Practice Address - Country:US
Practice Address - Phone:903-581-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-07
Last Update Date:2022-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8143TGOtherTEXAS OPTOMETRY BOARD