Provider Demographics
NPI:1669656799
Name:PATMICK LLC
Entity Type:Organization
Organization Name:PATMICK LLC
Other - Org Name:PATRICK OPTICAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-370-6118
Mailing Address - Street 1:2255 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1812
Mailing Address - Country:US
Mailing Address - Phone:817-370-6118
Mailing Address - Fax:817-370-7118
Practice Address - Street 1:2255 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1812
Practice Address - Country:US
Practice Address - Phone:817-370-6118
Practice Address - Fax:817-370-7118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDRO166332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier