Provider Demographics
NPI:1629241617
Name:MAPLEWOOD EYECARE CENTER
Entity Type:Organization
Organization Name:MAPLEWOOD EYECARE CENTER
Other - Org Name:LARRY D GUNNELL OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:GUNNELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:940-696-0296
Mailing Address - Street 1:3631 MAPLEWOOD AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2149
Mailing Address - Country:US
Mailing Address - Phone:940-696-0296
Mailing Address - Fax:940-696-0298
Practice Address - Street 1:3631 MAPLEWOOD AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2149
Practice Address - Country:US
Practice Address - Phone:940-696-0296
Practice Address - Fax:940-696-0298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2496TG332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMG0390637OtherDEA
TXMG0390637OtherDEA
TX00E04D0Medicare PIN
TXT13596Medicare UPIN