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General NPI Number Information
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NPI Number | 1639670011
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Entity Type | Organization
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Legal Business Name | OPTIC GALLERY NELLIS LLC
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Dates
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Enumeration Date | 02/22/2018
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Last Update Date | 02/22/2018
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Provider Practice Location Address
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Address Line | 111 N NELLIS BLVD STE 130
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City | LAS VEGAS
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State | NV
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Zip | 89110-6010
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Country | US
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Telephone | 702-820-2020
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Fax |
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Provider Business Mailing Address
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Address Line | 111 N NELLIS BLVD STE 130
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City | LAS VEGAS
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State | NV
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Zip | 89110-6010
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Country | US
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Telephone | 702-820-2020
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Fax |
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Authorized Official
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Title or Position | OWNER/OPTOMETRIS
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Name | MELISSA BEATY
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Credential | OD
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Telephone | 702-820-2020
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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 | 580
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License Number State | NV
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