Provider Demographics
NPI:1720862857
Name:111721 DELAWARE ACQUIRECO INC.
Entity Type:Organization
Organization Name:111721 DELAWARE ACQUIRECO INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF RETAIL
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:WIXSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-212-6707
Mailing Address - Street 1:5000 SW 75TH AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4468
Mailing Address - Country:US
Mailing Address - Phone:561-212-6707
Mailing Address - Fax:
Practice Address - Street 1:5975 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4048
Practice Address - Country:US
Practice Address - Phone:404-252-4111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier