Provider Demographics
NPI:1881040673
Name:COUTURE EYEWEAR
Entity type:Organization
Organization Name:COUTURE EYEWEAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:BAILEY
Authorized Official - Last Name:TRADER
Authorized Official - Suffix:
Authorized Official - Credentials:NC LICENSED OPTICIAN
Authorized Official - Phone:336-497-5391
Mailing Address - Street 1:1030 S MAIN ST
Mailing Address - Street 2:SUITE P
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7490
Mailing Address - Country:US
Mailing Address - Phone:333-497-5391
Mailing Address - Fax:336-497-4604
Practice Address - Street 1:1030 S MAIN ST
Practice Address - Street 2:SUITE P
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7490
Practice Address - Country:US
Practice Address - Phone:336-497-5391
Practice Address - Fax:336-497-4604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1638156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty