1013015114 NPI number — VISION OPTICS PC

Table of content: (NPI 1013015114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013015114 NPI number — VISION OPTICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VISION OPTICS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013015114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1305 SIDNEY BAKER ST STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERRVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78028-2737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-792-5880
Provider Business Mailing Address Fax Number:
830-792-4950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 SIDNEY BAKER ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-2737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-792-5880
Provider Business Practice Location Address Fax Number:
830-792-4950
Provider Enumeration Date:
09/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROTHERMEL
Authorized Official First Name:
PETER
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRINCIPAL
Authorized Official Telephone Number:
830-792-5880

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  04937T , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 066137301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 093056201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80933Q . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".