Basic Information
Provider Information
NPI: 1396307641
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HUMBLE
FirstName: CIARRA
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: OD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 210 FENNELL DR
Address2:  
City: MONROE
State: LA
PostalCode: 712033926
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1200 E ELDORADO PKWY STE 100
Address2:  
City: LITTLE ELM
State: TX
PostalCode: 750685582
CountryCode: US
TelephoneNumber: 9722920900
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/07/2019
LastUpdateDate: 07/07/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X9733TTXY Eye and Vision Services ProvidersOptometrist 

No ID Information.


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