Healthcare Provider Details

I. General information

NPI: 1407472376
Provider Name (Legal Business Name): OPTICAL BOUTIQUE AND EYECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 E PLEASANT RUN RD STE A
DESOTO TX
75115-4200
US

IV. Provider business mailing address

PO BOX 444
LANCASTER TX
75146-0444
US

V. Phone/Fax

Practice location:
  • Phone: 972-223-2020
  • Fax: 972-228-1860
Mailing address:
  • Phone: 972-223-2020
  • Fax: 972-228-1860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1201X
TaxonomyOptometric Assistant Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156FX1202X
TaxonomyOptometric Technician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIELLE GLOSTER
Title or Position: OWNER
Credential: O.D.
Phone: 972-223-2020