Provider Demographics
NPI:1386820421
Name:CUSTOM EYES, LLC
Entity Type:Organization
Organization Name:CUSTOM EYES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WOLOSIN
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC,NCLEC
Authorized Official - Phone:702-564-3678
Mailing Address - Street 1:PO BOX 230747
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89105-0747
Mailing Address - Country:US
Mailing Address - Phone:702-564-3678
Mailing Address - Fax:702-564-7552
Practice Address - Street 1:175 N STEPHANIE ST
Practice Address - Street 2:SUITE 130
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-8829
Practice Address - Country:US
Practice Address - Phone:702-564-3678
Practice Address - Fax:702-564-7552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-19
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV362332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier