Healthcare Provider Details

I. General information

NPI: 1114278066
Provider Name (Legal Business Name): XTREME OPTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W 3RD AVE SUITE D
CORSICANA TX
75110-4667
US

IV. Provider business mailing address

111 W 3RD AVE SUITE D
CORSICANA TX
75110-4667
US

V. Phone/Fax

Practice location:
  • Phone: 903-641-0060
  • Fax: 866-970-3838
Mailing address:
  • Phone: 903-641-0060
  • Fax: 866-970-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberDR4133
License Number StateTX

VIII. Authorized Official

Name: MRS. AMBER DORSEY
Title or Position: SOLE MEMBER/OWNER
Credential: LICENSED OPTICIAN
Phone: 903-641-0060