Provider Demographics
NPI:1023266863
Name:DEHAVEN OPTICAL CENTER
Entity type:Organization
Organization Name:DEHAVEN OPTICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL SERVICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWNDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-595-7510
Mailing Address - Street 1:908 NORTH PACIFIC
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:TX
Mailing Address - Zip Code:75773-1836
Mailing Address - Country:US
Mailing Address - Phone:903-595-4144
Mailing Address - Fax:903-526-5491
Practice Address - Street 1:908 NORTH PACIFIC
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-1836
Practice Address - Country:US
Practice Address - Phone:903-569-9945
Practice Address - Fax:903-569-9974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203580001Medicaid
TX6198840001Medicare NSC