=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720507247
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAREDO KIDS EYEGLASSES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2017
-----------------------------------------------------
Last Update Date | 09/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 E DEL MAR BLVD STE A125
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-6586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-489-6778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 E DEL MAR BLVD STE A125
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-6586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-489-6778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ANDRES GARIBI
-----------------------------------------------------
Credential | ABOC
-----------------------------------------------------
Telephone | 956-336-4628
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------