Healthcare Provider Details

I. General information

NPI: 1720862857
Provider Name (Legal Business Name): 111721 DELAWARE ACQUIRECO INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5975 ROSWELL RD
ATLANTA GA
30328-4048
US

IV. Provider business mailing address

5000 SW 75TH AVE STE 202
MIAMI FL
33155-4468
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-4111
  • Fax:
Mailing address:
  • Phone: 561-212-6707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: TYLER WIXSON
Title or Position: DIRECTOR OF RETAIL
Credential:
Phone: 561-212-6707