Basic Information
| Provider Information | |||||||||
| NPI: | 1962516708 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 20-20 SIGHT OF FORNEY P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 E. US HWY 80 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORNEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751268663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725222020 | ||||||||
| FaxNumber: | 9725521701 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 E. US HWY 80 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORNEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751268663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725522020 | ||||||||
| FaxNumber: | 9725521701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 03/02/2011 | ||||||||
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| AuthorizedOfficialLastName: | TARRANT | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9725222020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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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 | 196294601 | 05 | TX | MEDICAID |