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General NPI Number Information
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NPI Number | 1376097600
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Entity Type | Organization
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Legal Business Name | OPTIC GALLERY THE DISTRICT LLC
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Dates
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Enumeration Date | 08/03/2016
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Last Update Date | 08/03/2016
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Provider Practice Location Address
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Address Line | 2260 VILLAGE WALK DR STE 108
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City | HENDERSON
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State | NV
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Zip | 89052-5688
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Country | US
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Telephone | 702-871-3937
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Fax | 702-871-3936
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Provider Business Mailing Address
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Address Line | 2260 VILLAGE WALK DR STE 108
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City | HENDERSON
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State | NV
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Zip | 89052-5688
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Country | US
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Telephone | 702-871-3937
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Fax | 702-871-3936
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Authorized Official
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Title or Position | MANAGER
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Name | TRACY NGUYEN
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Credential |
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Telephone | 702-634-2020
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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 | 417
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License Number State | NV
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