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General NPI Number Information
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NPI Number | 1720862857
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Entity Type | Organization
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Legal Business Name | 111721 DELAWARE ACQUIRECO INC.
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Dates
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Enumeration Date | 08/21/2023
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Last Update Date | 08/21/2023
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Provider Practice Location Address
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Address Line | 5975 ROSWELL RD
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City | ATLANTA
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State | GA
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Zip | 30328-4048
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Country | US
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Telephone | 404-252-4111
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Fax |
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Provider Business Mailing Address
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Address Line | 5000 SW 75TH AVE STE 202
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City | MIAMI
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State | FL
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Zip | 33155-4468
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Country | US
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Telephone | 561-212-6707
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF RETAIL
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Name | TYLER WIXSON
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Credential |
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Telephone | 561-212-6707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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