| Organization Name: | CUSTOM QUALITY OPTICAL |
| NPI Number: | 1588685267 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JAY MATTHEW REAVIS (OWNER) |
| Mailing Address: | 1632 Pat Booker Rd Suite 124 Universal City |
| State: | TX US |
| Postal Code: | 781483552 |
| Phone Number: | 2109459226 |
| Fax Number: | 2105665914 |
| NPI Enumeration Date: | 07/21/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 156FX1800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Eye and Vision Services Providers |
| Taxonomy Classification: | Technician/Technologist |
| Taxonomy Specialization: | Optician |
| Taxonomy Definition: | |