Provider Demographics
NPI:1821564964
Name:SPECIALEYES OPTICAL, LLC
Entity Type:Organization
Organization Name:SPECIALEYES OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
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:817-529-9929
Mailing Address - Fax:817-529-9927
Practice Address - Street 1:2212 EMERY ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-1100
Practice Address - Country:US
Practice Address - Phone:940-312-5900
Practice Address - Fax:940-312-5901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-16
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287401803Medicaid
TX294486001Medicaid
TX323588905Medicaid
TX018440004Medicaid
TX166926901Medicaid
TX375326101Medicaid
TX145291402Medicaid
TX207716601Medicaid