1124220363 NPI number — MANN EYE CENTER, PA

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 1124220363 NPI number — MANN EYE CENTER, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANN EYE CENTER, PA
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:
1124220363
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 659506
Provider Second Line Business Mailing Address:
DEPT 2181
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78265-9506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-275-2457
Provider Business Mailing Address Fax Number:
713-275-2466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 VIA FORTUNA STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78746-7992
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-275-2457
Provider Business Practice Location Address Fax Number:
713-275-2466
Provider Enumeration Date:
06/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHEPPARD
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
713-275-2457

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , 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: 158554907 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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