1689765414 NPI number — LARRY WILKINSON

Table of content: (NPI 1689765414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689765414 NPI number — LARRY WILKINSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY WILKINSON
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:
VISION TRENDS EYE CARE
Provider Other Organization Name Type Code:
3
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:
1689765414
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 AVENUE I
Provider Second Line Business Mailing Address:
P O BOX 607
Provider Business Mailing Address City Name:
ROSENBERG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77471-3904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-342-4664
Provider Business Mailing Address Fax Number:
281-232-0894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 AVENUE I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSENBERG
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77471-3904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-342-4664
Provider Business Practice Location Address Fax Number:
281-232-0894
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILKINSON
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
(NMI)
Authorized Official Title or Position:
OWNER / OPTOMETRIST
Authorized Official Telephone Number:
281-342-4664

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  02165T , 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: 019274201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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