Basic Information
| Provider Information | |||||||||
| NPI: | 1871023531 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 1463 TSO PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4011 FM 1463 | ||||||||
| Address2: | |||||||||
| City: | KATY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816442020 | ||||||||
| FaxNumber: | 7134503609 | ||||||||
| Practice Location | |||||||||
| Address1: | 4011 FM 1463 | ||||||||
| Address2: | |||||||||
| City: | KATY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816442020 | ||||||||
| FaxNumber: | 7134503609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | READE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/OD | ||||||||
| AuthorizedOfficialTelephone: | 7134532972 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OWNER/OD | ||||||||
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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.