=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386188563
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR ALLEN'S EYE CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2016
-----------------------------------------------------
Last Update Date | 05/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3304 RICHMOND RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-0703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 430-200-0036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4401 GALLERIA OAKS DR, STE B
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-838-9063
-----------------------------------------------------
Fax | 833-811-8332
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING COORDINATOR
-----------------------------------------------------
Name | MRS. NICOLE CRIBBS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-838-9063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 05370TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------