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Organization

IDEA TO GROW

Active
Organization subpart
No

Provider details

NPI number
Authorized official
JACKE BENNETT (CREDENTIALING MANAGER)
(561) 612-4531
Entity
Organization

Contact information

Practice address
1050 MAYFIELD RD STE 100, GRAND PRAIRIE, TX 75052-6043
(469) 865-1380
(561) 828-8367
Mailing address
1050 MAYFIELD RD STE 100, GRAND PRAIRIE, TX 75052-6043
(561) 275-2020

Taxonomy

Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary

Other

Enumeration date
12/02/2020
Last updated
02/19/2021
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Product
  • Claims
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  • EDI platform