Basic Information
| Provider Information | |||||||||
| NPI: | 1467819730 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXARKANA EYE ASSOCIATES-BROKEN BOW BRANCH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2703 RICHMOND RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755032328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038380783 | ||||||||
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| Practice Location | |||||||||
| Address1: | 511 S PARK DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BROKEN BOW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747285329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805843434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2016 | ||||||||
| LastUpdateDate: | 10/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | FENTON | ||||||||
| AuthorizedOfficialFirstName: | ELVIN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9038380783 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.