1932629987 NPI number — 20/20 ICARE AND IWEAR, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932629987 NPI number — 20/20 ICARE AND IWEAR, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
20/20 ICARE AND IWEAR, PLLC
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:
1932629987
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 RHONE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-1449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-262-2145
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3510 S STATE HWY 161
Provider Second Line Business Practice Location Address:
SUITE 110
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:
972-264-7200
Provider Business Practice Location Address Fax Number:
972-264-7220
Provider Enumeration Date:
06/21/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DO
Authorized Official First Name:
LONG
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING OPTOMETRIST
Authorized Official Telephone Number:
817-262-2145

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  8143TG , 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)





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