Provider Demographics
NPI:1982290649
Name:PARK FOREST OPTICAL LLC
Entity Type:Organization
Organization Name:PARK FOREST OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:214-924-3341
Mailing Address - Street 1:11722 MARSH LN STE 350
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-2683
Mailing Address - Country:US
Mailing Address - Phone:214-902-9779
Mailing Address - Fax:214-902-8810
Practice Address - Street 1:11722 MARSH LN STE 350
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-2683
Practice Address - Country:US
Practice Address - Phone:214-902-9779
Practice Address - Fax:214-902-8810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty