Provider Demographics
NPI:1538405790
Name:GRAND PRAIRIE ADVANCED EYECARE INC
Entity type:Organization
Organization Name:GRAND PRAIRIE ADVANCED EYECARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-905-0444
Mailing Address - Street 1:5224 TX SOUTH 360
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052
Mailing Address - Country:US
Mailing Address - Phone:972-602-4545
Mailing Address - Fax:972-602-4546
Practice Address - Street 1:5224 TX SOUTH 360
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052
Practice Address - Country:US
Practice Address - Phone:972-602-4545
Practice Address - Fax:972-602-4546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-17
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX316869201Medicaid
TX270707Medicare PIN