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General NPI Number Information
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NPI Number | 1457537383
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Entity Type | Organization
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Legal Business Name | JERRY D REDWINE
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Dates
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Enumeration Date | 01/09/2008
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Last Update Date | 01/10/2008
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Provider Practice Location Address
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Address Line | 111 E 3RD ST
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City | MULESHOE
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State | TX
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Zip | 79347-3801
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Country | US
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Telephone | 806-272-4705
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Fax | 806-272-3824
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Provider Business Mailing Address
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Address Line | PO BOX 1011
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City | MULESHOE
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State | TX
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Zip | 79347-1011
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Country | US
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Telephone | 806-272-4705
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Fax | 806-272-3824
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. DONNA JEAN REDWINE
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Credential |
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Telephone | 806-272-4705
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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 | 2296T
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License Number State | TX
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