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General NPI Number Information
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NPI Number | 1689941411
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Entity Type | Organization
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Legal Business Name | OPTIC GALLERY SAHARA LLC
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Dates
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Enumeration Date | 11/22/2011
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Last Update Date | 11/22/2011
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Provider Practice Location Address
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Address Line | 2580 S DECATUR BLVD STE 6
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City | LAS VEGAS
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State | NV
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Zip | 89102-5513
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Country | US
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Telephone | 702-893-3937
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Fax | 702-893-3429
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Provider Business Mailing Address
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Address Line | 2580 S DECATUR BLVD STE 6
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City | LAS VEGAS
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State | NV
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Zip | 89102-5513
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Country | US
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Telephone | 702-893-3937
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Fax | 702-893-3429
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | ROGER PAEZ
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Credential | O.D
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Telephone | 702-893-3937
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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 | 507
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License Number State | NV
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