Healthcare Provider Details

I. General information

NPI: 1932607298
Provider Name (Legal Business Name): EYEWEAR BOUTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 01/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 MARYLAND AVE
WILMINGTON DE
19805-4605
US

IV. Provider business mailing address

1902 MARYLAND AVE
WILMINGTON DE
19805-4605
US

V. Phone/Fax

Practice location:
  • Phone: 302-442-3005
  • Fax:
Mailing address:
  • Phone: 302-442-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number20170920124
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number20170920124
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number20170920124
License Number StateDE

VIII. Authorized Official

Name: MR. PAUL FLOWERS
Title or Position: OWNER/ OPTICIAN
Credential:
Phone: 302-442-3005