Healthcare Provider Details

I. General information

NPI: 1346887304
Provider Name (Legal Business Name): MEL ROCKWALL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E BROAD ST STE 109
MANSFIELD TX
76063-4349
US

IV. Provider business mailing address

1784 W MCDERMOTT DR STE 110
ALLEN TX
75013-3395
US

V. Phone/Fax

Practice location:
  • Phone: 682-341-3921
  • Fax: 561-828-8367
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: JACKIE BENNETT
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 561-433-6009