Provider Demographics
NPI:1447428701
Name:JEFF WERTZ
Entity Type:Organization
Organization Name:JEFF WERTZ
Other - Org Name:EYEWEAR OUTLET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-296-7175
Mailing Address - Street 1:1001 N I-27 STE 206
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:79072-3903
Mailing Address - Country:US
Mailing Address - Phone:806-296-7175
Mailing Address - Fax:806-296-0633
Practice Address - Street 1:1001 N I-27 STE 206
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:TX
Practice Address - Zip Code:79072-3903
Practice Address - Country:US
Practice Address - Phone:806-296-7175
Practice Address - Fax:806-296-0633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0662777-03Medicaid
TX4465200001Medicare NSC