1073607370 NPI number — BRAZOSPORT PROFESSIONAL EYE CLINIC INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073607370 NPI number — BRAZOSPORT PROFESSIONAL EYE CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAZOSPORT PROFESSIONAL EYE CLINIC INC
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:
6
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:
1073607370
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
123 CIRCLE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE JACKSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77566-5233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-299-3250
Provider Business Mailing Address Fax Number:
979-299-1724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 CIRCLE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE JACKSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77566-5233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-299-3250
Provider Business Practice Location Address Fax Number:
979-299-1724
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PROVENZANO
Authorized Official First Name:
MARK
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
979-299-3250

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3979TG , 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: 0195042 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80775Q . This is a "BCBS OF TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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