1023375094 NPI number — NAVASOTA EYE CARE CENTER PLLC

Table of content: (NPI 1023375094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023375094 NPI number — NAVASOTA EYE CARE CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NAVASOTA EYE CARE 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:
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:
1023375094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2320 E VILLA MARIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRYAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77802-2549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-779-9000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 E WASHINGTON AVE STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAVASOTA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77868-3001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-779-9000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DOBSON
Authorized Official First Name:
BELINDA
Authorized Official Middle Name:
SHAE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
979-779-9000

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  7126TG , 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: 613237 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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