Healthcare Provider Details

I. General information

NPI: 1992192967
Provider Name (Legal Business Name): DEHAVEN OPTICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2015
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MOCKINGBIRD LANE LONESTAR OPTICAL
SULPHUR SPRINGS TX
75482-4853
US

IV. Provider business mailing address

1424 EAST FRONT DEHAVEN OPTICAL CENTER DBA LONESTAR OPTICAL
TYLER TX
75702-8501
US

V. Phone/Fax

Practice location:
  • Phone: 903-439-2020
  • Fax: 903-439-2020
Mailing address:
  • Phone: 903-595-4144
  • Fax: 903-526-5491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: AVA B. ASHBY
Title or Position: FINANCIAL SERVICE MGR.
Credential:
Phone: 903-595-7510