Provider Demographics
NPI:1851762272
Name:PARK FOREST EYE CARE, PLLC
Entity Type:Organization
Organization Name:PARK FOREST EYE CARE, PLLC
Other - Org Name:FIRST EYE CARE PARK FOREST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOURQUE-WIMBISH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-241-8084
Mailing Address - Street 1:11888 MARSH LN STE 414
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-8083
Mailing Address - Country:US
Mailing Address - Phone:972-241-8084
Mailing Address - Fax:
Practice Address - Street 1:11888 MARSH LN
Practice Address - Street 2:SUITE 414
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-8083
Practice Address - Country:US
Practice Address - Phone:972-960-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5376TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty