=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275202244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYESCOPELV LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2021
-----------------------------------------------------
Last Update Date | 09/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5940 S RAINBOW BLVD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89118-2506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-751-1745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5940 S RAINBOW BLVD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89118-2506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-751-1745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MRS. KRIS ALLEN
-----------------------------------------------------
Credential | NV LICENSED OPTICIAN
-----------------------------------------------------
Telephone | 702-751-1745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------