Provider Demographics
NPI:1164294807
Name:MODERN SPECTACLE EYECARE PLLC
Entity Type:Organization
Organization Name:MODERN SPECTACLE EYECARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LESAGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:713-732-6385
Mailing Address - Street 1:6336 GASTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-3926
Mailing Address - Country:US
Mailing Address - Phone:469-225-9959
Mailing Address - Fax:469-225-3537
Practice Address - Street 1:6336 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-3926
Practice Address - Country:US
Practice Address - Phone:469-225-9959
Practice Address - Fax:469-225-3537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-26
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty