Basic Information
| Provider Information | |||||||||
| NPI: | 1720447071 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOOMTOWN VISION PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 S AVENUE D | ||||||||
| Address2: | |||||||||
| City: | BURKBURNETT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763543564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405691177 | ||||||||
| FaxNumber: | 9405694969 | ||||||||
| Practice Location | |||||||||
| Address1: | 312 S AVENUE D | ||||||||
| Address2: | |||||||||
| City: | BURKBURNETT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763543564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405691177 | ||||||||
| FaxNumber: | 9405694969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2016 | ||||||||
| LastUpdateDate: | 02/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | SOLOMONS | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9405691177 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD/OWNER | ||||||||
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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 |
No ID Information.