1114189032 NPI number — KEITH J. ERMIS OD PC

Table of content: (NPI 1114189032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114189032 NPI number — KEITH J. ERMIS OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEITH J. ERMIS OD 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:
THE FAMILY VISION CENTER
Provider Other Organization Name Type Code:
3
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:
1114189032
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 N FULTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHARTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77488-3128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-532-0805
Provider Business Mailing Address Fax Number:
979-532-2084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 N FULTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHARTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77488-3128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-532-0805
Provider Business Practice Location Address Fax Number:
979-532-2084
Provider Enumeration Date:
07/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ERMIS
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
979-532-0805

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1124299-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com