Provider Demographics
NPI:1932398609
Name:PROMENADE OPTICAL
Entity Type:Organization
Organization Name:PROMENADE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MANON
Authorized Official - Middle Name:
Authorized Official - Last Name:TREYBIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-238-0815
Mailing Address - Street 1:650 N COIT RD
Mailing Address - Street 2:#2325
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-5406
Mailing Address - Country:US
Mailing Address - Phone:972-238-0815
Mailing Address - Fax:972-238-5458
Practice Address - Street 1:650 N COIT RD
Practice Address - Street 2:#2325
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-5406
Practice Address - Country:US
Practice Address - Phone:972-238-0815
Practice Address - Fax:972-238-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0963490001Medicare NSC