=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801339395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRIENDLY EYE CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2016
-----------------------------------------------------
Last Update Date | 03/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3801 LAKEVIEW PKWY STE 400
-----------------------------------------------------
City | ROWLETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75088-4079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-931-0130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3801 LAKEVIEW PKWY STE 400
-----------------------------------------------------
City | ROWLETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75088-4079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-931-0130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTMETRIST/OWNER
-----------------------------------------------------
Name | DR. DEISY BAUTISTA
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 469-931-0130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 8076TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------