1538405790 NPI number — GRAND PRAIRIE ADVANCED EYECARE INC

Table of content: MRS. REBECCA HYDE MILES P.T. (NPI 1033362579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538405790 NPI number — GRAND PRAIRIE ADVANCED EYECARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND PRAIRIE ADVANCED EYECARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538405790
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5224 TX SOUTH 360
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GRAND PRAIRIE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-602-4545
Provider Business Mailing Address Fax Number:
972-602-4546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5224 TX SOUTH 360
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GRAND PRAIRIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-602-4545
Provider Business Practice Location Address Fax Number:
972-602-4546
Provider Enumeration Date:
12/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PRICE
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-905-0444

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 316869201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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