=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538663877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE FOR BEAUTY MED SPA & GBC FAMILY MEDICINE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2018
-----------------------------------------------------
Last Update Date | 03/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 227 S GUN BARREL LN
-----------------------------------------------------
City | GUN BARREL CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75156-3851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-887-8884
-----------------------------------------------------
Fax | 903-887-7808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 227 S GUN BARREL LN
-----------------------------------------------------
City | GUN BARREL CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75156-3851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-887-8884
-----------------------------------------------------
Fax | 903-887-7808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARY CATHERINE MOODY
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 903-887-8884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | AP126911
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP126911
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------