Healthcare Provider Details

I. General information

NPI: 1134889728
Provider Name (Legal Business Name): FIRST IMPRESSIONS OPTOMETRIC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 SAGAMORE PKWY S
LAFAYETTE IN
47905-5109
US

IV. Provider business mailing address

175 E HOUSTON ST
SAN ANTONIO TX
78205-2255
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-8010
  • Fax:
Mailing address:
  • Phone: 726-444-4078
  • 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: AJA BOWLING
Title or Position: OWNER
Credential: OD
Phone: 726-444-4078