Provider Demographics
NPI:1356126627
Name:SNOWBALLS EYE BOUTIQUE LLC
Entity type:Organization
Organization Name:SNOWBALLS EYE BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:KYLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTANS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-456-7421
Mailing Address - Street 1:116 OLD STAGE RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-8948
Mailing Address - Country:US
Mailing Address - Phone:719-626-4234
Mailing Address - Fax:
Practice Address - Street 1:116 OLD STAGE RD UNIT A
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-8948
Practice Address - Country:US
Practice Address - Phone:719-626-4234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty