1093872848 NPI number — TEXAS SPECTACLES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093872848 NPI number — TEXAS SPECTACLES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS SPECTACLES LLC
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:
1093872848
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 576
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78292-0576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-379-3937
Provider Business Mailing Address Fax Number:
830-303-2367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1551 WALNUT AVENUE
Provider Second Line Business Practice Location Address:
STE 25
Provider Business Practice Location Address City Name:
NEW BRAUNFELS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-379-3937
Provider Business Practice Location Address Fax Number:
830-303-2367
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KAVANAGH
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER,PHYSICIAN
Authorized Official Telephone Number:
830-379-3937

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  L1354 , 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)





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