Provider Demographics
NPI:1679028542
Name:SPECIALEYES OPTICAL, LLC
Entity Type:Organization
Organization Name:SPECIALEYES OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:PACKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-529-9949
Mailing Address - Street 1:321 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1016
Mailing Address - Country:US
Mailing Address - Phone:817-529-9949
Mailing Address - Fax:217-529-9943
Practice Address - Street 1:105 RIVER OAKES DR.
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-529-9949
Practice Address - Fax:817-529-9943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7350TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018440004Medicaid
TX145291402Medicaid
TX287401803Medicaid
TX166926901Medicaid
TX323588905Medicaid
TX294486001Medicaid
TX207716601Medicaid