Basic Information
| Provider Information | |||||||||
| NPI: | 1508146374 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTICAL ILLUSIONZ INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5800 BELLAIRE BLVD | ||||||||
| Address2: | STE 112 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770815537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137717867 | ||||||||
| FaxNumber: | 7137717869 | ||||||||
| Practice Location | |||||||||
| Address1: | 5800 BELLAIRE BLVD | ||||||||
| Address2: | STE 112 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770815537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137717867 | ||||||||
| FaxNumber: | 7137717869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2011 | ||||||||
| LastUpdateDate: | 02/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | FUENTES | ||||||||
| AuthorizedOfficialFirstName: | JONNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7137717867 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | ABOC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.