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General NPI Number Information
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NPI Number | 1114278066
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Entity Type | Organization
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Legal Business Name | XTREME OPTICS LLC
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Dates
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Enumeration Date | 10/01/2012
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Last Update Date | 10/01/2012
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Provider Practice Location Address
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Address Line | 111 W 3RD AVE SUITE D
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City | CORSICANA
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State | TX
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Zip | 75110-4667
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Country | US
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Telephone | 903-641-0060
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Fax | 866-970-3838
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Provider Business Mailing Address
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Address Line | 111 W 3RD AVE SUITE D
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City | CORSICANA
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State | TX
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Zip | 75110-4667
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Country | US
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Telephone | 903-641-0060
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Fax | 866-970-3838
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Authorized Official
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Title or Position | SOLE MEMBER/OWNER
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Name | MRS. AMBER DORSEY
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Credential | LICENSED OPTICIAN
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Telephone | 903-641-0060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | DR4133
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License Number State | TX
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