Provider Demographics
NPI:1336492453
Name:HEADWACK LLC
Entity Type:Organization
Organization Name:HEADWACK LLC
Other - Org Name:RELENSMYFRAMES.COM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-604-5062
Mailing Address - Street 1:1958 PRODUCTION CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2104
Mailing Address - Country:US
Mailing Address - Phone:800-604-5062
Mailing Address - Fax:
Practice Address - Street 1:1958 PRODUCTION CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-2104
Practice Address - Country:US
Practice Address - Phone:800-604-5062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier