Provider Demographics
NPI:1932607298
Name:EYEWEAR BOUTIQUE
Entity Type:Organization
Organization Name:EYEWEAR BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-442-3005
Mailing Address - Street 1:1902 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-4605
Mailing Address - Country:US
Mailing Address - Phone:302-442-3005
Mailing Address - Fax:
Practice Address - Street 1:1902 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-4605
Practice Address - Country:US
Practice Address - Phone:302-442-3005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE20170920124156FC0800X, 156FC0801X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Single Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Single Specialty