1255338612 NPI number — CLEAR LAKE EYE CENTER LLP

Table of content: (NPI 1255338612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255338612 NPI number — CLEAR LAKE EYE CENTER LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEAR LAKE EYE CENTER LLP
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:
BERKELEY EYE CENTER CLEAR LAKE
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:
1255338612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 WESLAYAN
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-526-1600
Provider Business Mailing Address Fax Number:
713-526-6520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1046 HERCULES
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-488-0070
Provider Business Practice Location Address Fax Number:
281-488-0078
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MICHELETTI
Authorized Official First Name:
MARK
Authorized Official Middle Name:
F
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
713-526-1600

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0059FA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4393740001 . This is a "PALMETTO GBA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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