Provider Demographics
NPI:1992192967
Name:DEHAVEN OPTICAL CENTER
Entity Type:Organization
Organization Name:DEHAVEN OPTICAL CENTER
Other - Org Name:LONESTAR OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL SERVICE MGR.
Authorized Official - Prefix:
Authorized Official - First Name:AVA
Authorized Official - Middle Name:B
Authorized Official - Last Name:ASHBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-595-7510
Mailing Address - Street 1:1424 EAST FRONT
Mailing Address - Street 2:DEHAVEN OPTICAL CENTER DBA LONESTAR OPTICAL
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8501
Mailing Address - Country:US
Mailing Address - Phone:903-595-4144
Mailing Address - Fax:903-526-5491
Practice Address - Street 1:1100 MOCKINGBIRD LANE
Practice Address - Street 2:LONESTAR OPTICAL
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-4853
Practice Address - Country:US
Practice Address - Phone:903-439-2020
Practice Address - Fax:903-439-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier