Provider Demographics
NPI:1790176022
Name:SPECTACULARX
Entity Type:Organization
Organization Name:SPECTACULARX
Other - Org Name:PEARLE VISION #8699
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIRGEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-659-9189
Mailing Address - Street 1:8235 AGORA PKWY STE 123
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:TX
Mailing Address - Zip Code:78154-1335
Mailing Address - Country:US
Mailing Address - Phone:210-659-9189
Mailing Address - Fax:
Practice Address - Street 1:8235 AGORA PKWY STE 123
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:TX
Practice Address - Zip Code:78154-1335
Practice Address - Country:US
Practice Address - Phone:210-659-9189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty