1467657916 NPI number — PHILLIPS VISION CLINIC LLC

Table of content: (NPI 1467657916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467657916 NPI number — PHILLIPS VISION CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILLIPS VISION CLINIC 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:
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:
1467657916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4109 MOORES LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75503-2159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-329-5051
Provider Business Mailing Address Fax Number:
903-329-5053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4504 TEXAS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-3027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-792-3705
Provider Business Practice Location Address Fax Number:
903-794-5008
Provider Enumeration Date:
06/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
903-329-5051

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  5480T , 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: 98441 . This is a "ARKANSAS BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 01915611 . This is a "TEXAS MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 140981722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41046137 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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