Healthcare Provider Details

I. General information

NPI: 1134898919
Provider Name (Legal Business Name): SMAZY ENTERPRISE IV LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/07/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 S INTERSTATE 35 STE A250
AUSTIN TX
78748-1998
US

IV. Provider business mailing address

9900 S INTERSTATE 35 STE A250
AUSTIN TX
78748-1998
US

V. Phone/Fax

Practice location:
  • Phone: 561-275-2020
  • Fax:
Mailing address:
  • Phone:
  • 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: DANIEL GARZA
Title or Position: CREDENTALING MANAGER
Credential:
Phone: 561-720-6423