Basic Information
| Provider Information | |||||||||
| NPI: | 1881232965 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AEG TEXAS PROFESSIONAL PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 E BROADWAY | ||||||||
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| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 10TH ST STE 3 | ||||||||
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| City: | FLORESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781143197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8303937744 | ||||||||
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| ProviderEnumerationDate: | 12/19/2019 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHORT | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 1846298186 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.