Healthcare Provider Details

I. General information

NPI: 1699811828
Provider Name (Legal Business Name): EYEGLASS WORLD, LLC 75
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2533 N 75TH AVE
PHOENIX AZ
85035-1211
US

IV. Provider business mailing address

3801 S CONGRESS AVE
LAKE WORTH FL
33461-4140
US

V. Phone/Fax

Practice location:
  • Phone: 623-247-2706
  • Fax: 623-247-1315
Mailing address:
  • Phone: 561-965-9110
  • Fax: 561-642-4063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number03011217
License Number StateAZ

VIII. Authorized Official

Name: MR. BEN COOK
Title or Position: COO
Credential:
Phone: 561-965-9110