Healthcare Provider Details

I. General information

NPI: 1023266863
Provider Name (Legal Business Name): DEHAVEN OPTICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 NORTH PACIFIC
MINEOLA TX
75773-1836
US

IV. Provider business mailing address

908 NORTH PACIFIC
MINEOLA TX
75773-1836
US

V. Phone/Fax

Practice location:
  • Phone: 903-569-9945
  • Fax: 903-569-9974
Mailing address:
  • Phone: 903-595-4144
  • Fax: 903-526-5491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: GINA LOWNDES
Title or Position: FINANCIAL SERVICE MANAGER
Credential:
Phone: 903-595-7510