Provider Demographics
NPI:1992903900
Name:GRACE EYE CLINIC PA
Entity type:Organization
Organization Name:GRACE EYE CLINIC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YOUNGSON
Authorized Official - Middle Name:
Authorized Official - Last Name:JOE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-458-7979
Mailing Address - Street 1:13331 PRESTON RD
Mailing Address - Street 2:1068
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1130
Mailing Address - Country:US
Mailing Address - Phone:972-458-7979
Mailing Address - Fax:972-458-7503
Practice Address - Street 1:13331 PRESTON RD
Practice Address - Street 2:1068
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-1130
Practice Address - Country:US
Practice Address - Phone:972-458-7979
Practice Address - Fax:972-458-7503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07005TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty