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General NPI Number Information
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NPI Number | 1750627188
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Entity Type | Organization
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Legal Business Name | EYE RISE CLINIC
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Dates
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Enumeration Date | 12/12/2012
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Last Update Date | 10/07/2024
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Provider Practice Location Address
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Address Line | 6760 WESTWORTH BLVD
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City | WESTWORTH VILLAGE
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State | TX
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Zip | 76114-4002
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Country | US
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Telephone | 682-430-1487
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Fax |
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Provider Business Mailing Address
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Address Line | 2928 BRITTLEBUSH DR
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City | FORT WORTH
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State | TX
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Zip | 76108-2388
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Country | US
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Telephone | 682-430-1487
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JACQUELINE HENRIQUEZ
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Credential | OD
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Telephone | 787-549-8025
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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 | 7498
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License Number State | TX
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