=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992271480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLSTON EYE CARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2018
-----------------------------------------------------
Last Update Date | 10/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3150 E BROAD ST STE 120
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-301-5745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5400 PRESTON OAKS RD APT 4014
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75254-8483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-301-5745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/OWNER
-----------------------------------------------------
Name | DR. BENJAMIN DEAN COLSTON
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 817-301-5745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------