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

Table of content: (NPI 1932629987)

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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