Basic Information
Provider Information | |||||||||
NPI: | 1528549839 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHELLY BLAKER OD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HILL COUNTRY VISION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 205B W WATER ST | ||||||||
Address2: |   | ||||||||
City: | KERRVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 780284252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8308962600 | ||||||||
FaxNumber: | 8302576419 | ||||||||
Practice Location | |||||||||
Address1: | 1620 AVENUE M | ||||||||
Address2: |   | ||||||||
City: | HONDO | ||||||||
State: | TX | ||||||||
PostalCode: | 788611733 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8307412634 | ||||||||
FaxNumber: | 8304264495 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2018 | ||||||||
LastUpdateDate: | 08/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILLIAMS | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8309972504 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X |   |   | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
No ID Information.