MEDICARE: CUSTOM QUALITY OPTICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician

General Provider Information

NPI Number	:	1588685267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOM QUALITY OPTICAL

Provider Business Mailing Address
First Line	:	1632 PAT BOOKER RD
Second Line	:	SUITE 124
City	:	UNIVERSAL CITY
State	:	TX
Zip	:	78148-3552
Country	:	US
Telephone Number	:	210-945-9226
Fax Number	:	210-566-5914

Provider Business Practice Location Address
First Line	:	1632 PAT BOOKER RD
Second Line	:	SUITE 124
City	:	UNIVERSAL CITY
State	:	TX
Zip	:	78148-3552
Country	:	US
Telephone Number	:	210-945-9226
Fax Number	:	210-566-5914

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JAY MATTHEW REAVIS
Credential	:	OPTICIAN
Telephone Number	:	210-945-9226

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	08/22/2020

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