1649594250 NPI number — ID VISION CENTER PLLC

Table of content: (NPI 1649594250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649594250 NPI number — ID VISION CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ID VISION CENTER PLLC
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:
1649594250
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17454 NORTHWEST FWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77040-1002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-372-6686
Provider Business Mailing Address Fax Number:
888-876-6445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17454 NORTHWEST FWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77040-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-372-6686
Provider Business Practice Location Address Fax Number:
888-876-6445
Provider Enumeration Date:
03/25/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
HANH
Authorized Official Middle Name:
MK
Authorized Official Title or Position:
DOCTOR OF OPTOMETRY/ OWNER
Authorized Official Telephone Number:
281-372-6686

Provider Taxonomy Codes

  • Taxonomy code: 152WV0400X , with the licence number:  05739TG , 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: 05739TG . This is a "OPTOMETRY LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".