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General NPI Number Information
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NPI Number | 1124573092
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Entity Type | Organization
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Legal Business Name | SPECIALEYES OPTICAL, LLC
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Dates
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Enumeration Date | 08/22/2016
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Last Update Date | 08/22/2016
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Provider Practice Location Address
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Address Line | 1106 ALEXIS CT
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City | MANSFIELD
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State | TX
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Zip | 76063-3338
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Country | US
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Telephone | 817-529-9929
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Fax | 817-529-9927
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Provider Business Mailing Address
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Address Line | 321 S HENDERSON ST
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City | FORT WORTH
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State | TX
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Zip | 76104-1016
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Country | US
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Telephone | 817-529-9929
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Fax | 817-529-9927
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Authorized Official
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Title or Position | MEMBER
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Name | DR. ERIC ALAN PACKWOOD
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Credential | MD
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Telephone | 817-529-9949
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 7210TG
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License Number State | TX
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