Basic Information
| Provider Information | |||||||||
| NPI: | 1649203308 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VISIONWORKS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VISIONWORKS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 E HOUSTON ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782052255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105246803 | ||||||||
| FaxNumber: | 2105246587 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 INDEPENDENCE CENTER | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167950011 | ||||||||
| FaxNumber: | 8167958267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 07/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | MCDONALD | ||||||||
| AuthorizedOfficialFirstName: | DOLSIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MVC CONTRACTS & CREDENTIALING MANAG | ||||||||
| AuthorizedOfficialTelephone: | 2105246663 | ||||||||
| 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 | 507520005 | 05 | MO | MEDICAID |