Provider Demographics
NPI:1508557216
Name:EYES WYDE SHUT INC.
Entity Type:Organization
Organization Name:EYES WYDE SHUT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:KINENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DENT-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-777-0801
Mailing Address - Street 1:1964 SLIPPERY ROCK LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-0005
Mailing Address - Country:US
Mailing Address - Phone:980-777-0801
Mailing Address - Fax:
Practice Address - Street 1:1209B S YORK ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-6127
Practice Address - Country:US
Practice Address - Phone:980-777-0801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health