=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689252983
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | I&M OPTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2021
-----------------------------------------------------
Last Update Date | 01/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 E FM 544 STE 210
-----------------------------------------------------
City | MURPHY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75094-4093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-828-8367
-----------------------------------------------------
Fax | 561-828-8367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6415 ATHENEE LN
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75035-0369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-610-6818
-----------------------------------------------------
Fax | 561-828-8367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | DANIEL GARZA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-843-1393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------