1063421584 NPI number — CAROLYN LEE HELBERT GREEN

Table of content: CAROLYN LEE HELBERT GREEN (NPI 1063421584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063421584 NPI number — CAROLYN LEE HELBERT GREEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HELBERT GREEN
Provider First Name:
CAROLYN
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ASSOCIATES
Provider Other First Name:
COLLEYVILLE
Provider Other Middle Name:
VISION
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1063421584
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1213 HALL JOHNSON RD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
COLLEYVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76034-5847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-428-0400
Provider Business Mailing Address Fax Number:
817-428-0457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1213 HALL JOHNSON RD
Provider Second Line Business Practice Location Address:
SUITE # 300
Provider Business Practice Location Address City Name:
COLLEYVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76034-5847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-428-0400
Provider Business Practice Location Address Fax Number:
817-428-0457
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  03802TG , 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: 03802TG . This is a "OPTOMETRY BOARD LICENSE #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1336326966 . This is a "GROUP NPI NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: MH0879063 . This is a "DHE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: W0122304 . This is a "DPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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