1679028542 NPI number — SPECIALEYES OPTICAL, LLC

Table of content: (NPI 1679028542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679028542 NPI number — SPECIALEYES OPTICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALEYES OPTICAL, LLC
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:
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:
1679028542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
321 S HENDERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-1016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-529-9949
Provider Business Mailing Address Fax Number:
217-529-9943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
129 CHANDLER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KELLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76248-3717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-529-9949
Provider Business Practice Location Address Fax Number:
817-529-9943
Provider Enumeration Date:
08/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PACKWOOD
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
817-529-9949

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  7350TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 018440004 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145291402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 287401803 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166926901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 323588905 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 294486001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 207716601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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