=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023799871
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYEVIBE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2023
-----------------------------------------------------
Last Update Date | 07/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9051 HICKORY PL
-----------------------------------------------------
City | THORNTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80229-7936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-935-8689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12939 E 106TH WAY
-----------------------------------------------------
City | COMMERCE CITY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80022-0627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-935-8689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | JAY MARTINEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 720-935-8689
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------