Provider Demographics
NPI:1699811828
Name:EYEGLASS WORLD, LLC 75
Entity Type:Organization
Organization Name:EYEGLASS WORLD, LLC 75
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-965-9110
Mailing Address - Street 1:3801 S CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-4140
Mailing Address - Country:US
Mailing Address - Phone:561-965-9110
Mailing Address - Fax:561-642-4063
Practice Address - Street 1:2533 N 75TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85035-1211
Practice Address - Country:US
Practice Address - Phone:623-247-2706
Practice Address - Fax:623-247-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03011217332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier