Provider Demographics
NPI:1154506822
Name:PACK OPTICAL
Entity Type:Organization
Organization Name:PACK OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-831-6141
Mailing Address - Street 1:1217 OAK KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76117-5505
Mailing Address - Country:US
Mailing Address - Phone:817-831-6141
Mailing Address - Fax:
Practice Address - Street 1:1217 OAK KNOLL DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76117-5505
Practice Address - Country:US
Practice Address - Phone:817-831-6141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0984910001Medicare NSC