Healthcare Provider Details

I. General information

NPI: 1770666521
Provider Name (Legal Business Name): CARRIE DIVIN O. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 NORTH INTERSTATE HIGHWAY 35
BELLMEAD TX
76705
US

IV. Provider business mailing address

267 BOLTON CIR
WEST TX
76691-2400
US

V. Phone/Fax

Practice location:
  • Phone: 254-867-1957
  • Fax: 254-867-8445
Mailing address:
  • Phone: 254-867-1957
  • Fax: 254-867-8445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5927 TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: