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General NPI Number Information
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NPI Number | 1245597301
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Entity Type | Organization
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Legal Business Name | MD CONNALLY LLC
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Dates
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Enumeration Date | 04/13/2012
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Last Update Date | 04/13/2012
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Provider Practice Location Address
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Address Line | 2529 S MAIN ST SUITE 102
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City | WEATHERFORD
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State | TX
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Zip | 76087-5154
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Country | US
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Telephone | 817-550-8021
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Fax | 807-458-9879
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Provider Business Mailing Address
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Address Line | 2529 S MAIN ST SUITE 102
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City | WEATHERFORD
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State | TX
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Zip | 76087-5154
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Country | US
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Telephone | 817-550-8021
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Fax | 807-458-9879
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL CONNALLY
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Credential | OPTICIAN
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Telephone | 817-550-8021
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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 |
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License Number State |
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