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General NPI Number Information
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NPI Number | 1174940464
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Entity Type | Organization
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Legal Business Name | BLUE MOON OPTICAL
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Dates
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Enumeration Date | 03/25/2014
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Last Update Date | 03/25/2014
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Provider Practice Location Address
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Address Line | 121 W SAN ANTONIO ST
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City | SAN MARCOS
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State | TX
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Zip | 78666-5551
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Country | US
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Telephone | 805-710-2445
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Fax |
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Provider Business Mailing Address
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Address Line | 10800 RIVER PLANTATION DR
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City | AUSTIN
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State | TX
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Zip | 78747-1482
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Country | US
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Telephone | 805-710-2445
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL PATRICK DUFFY
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Credential | DO
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Telephone | 805-710-2445
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 189067
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License Number State | TX
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