Basic Information
| Provider Information | |||||||||
| NPI: | 1134198518 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHLINE TSO PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHLINE TEXAS STATE OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 UVALDE RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770153708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134532972 | ||||||||
| FaxNumber: | 7134503609 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 NORTH FWY | ||||||||
| Address2: | SUITE B300 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770223604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136972081 | ||||||||
| FaxNumber: | 7136974339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 02/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HR DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7134532972 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1551392-01 | 05 | TX | MEDICAID |