=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669816849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 20-20 SIGHT OF LAKEWOOD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2013
-----------------------------------------------------
Last Update Date | 08/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1905 ABRAMS RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75214-3916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-821-2020
-----------------------------------------------------
Fax | 972-264-7220
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1905 ABRAMS RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75214-3916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-821-2020
-----------------------------------------------------
Fax | 214-821-2025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. LARRY DON TARRANT
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 214-773-3457
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 5597TG
-----------------------------------------------------
License Number State |
-----------------------------------------------------