Provider Demographics
NPI:1407472376
Name:OPTICAL BOUTIQUE AND EYECARE
Entity Type:Organization
Organization Name:OPTICAL BOUTIQUE AND EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-223-2020
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-0444
Mailing Address - Country:US
Mailing Address - Phone:972-223-2020
Mailing Address - Fax:972-228-1860
Practice Address - Street 1:1233 E PLEASANT RUN RD STE A
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4200
Practice Address - Country:US
Practice Address - Phone:972-223-2020
Practice Address - Fax:972-228-1860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric AssistantGroup - Multi-Specialty
No156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric TechnicianGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty