Provider Demographics
NPI:1376097600
Name:OPTIC GALLERY THE DISTRICT LLC
Entity Type:Organization
Organization Name:OPTIC GALLERY THE DISTRICT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-634-2020
Mailing Address - Street 1:2260 VILLAGE WALK DR
Mailing Address - Street 2:STE 108
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5688
Mailing Address - Country:US
Mailing Address - Phone:702-871-3937
Mailing Address - Fax:702-871-3936
Practice Address - Street 1:2260 VILLAGE WALK DR
Practice Address - Street 2:STE 108
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5688
Practice Address - Country:US
Practice Address - Phone:702-871-3937
Practice Address - Fax:702-871-3936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty