Provider Demographics
NPI:1003399098
Name:OMNI VISION III
Entity Type:Organization
Organization Name:OMNI VISION III
Other - Org Name:OMNI VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THANH
Authorized Official - Middle Name:QUOC
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:832-331-9831
Mailing Address - Street 1:120 EMPRESARIO DRIVE
Mailing Address - Street 2:STE 111
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253
Mailing Address - Country:US
Mailing Address - Phone:210-257-0940
Mailing Address - Fax:210-855-7240
Practice Address - Street 1:120 EMPRESARIO DRIVE
Practice Address - Street 2:STE 111
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253
Practice Address - Country:US
Practice Address - Phone:210-257-0940
Practice Address - Fax:210-855-7240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-14
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX323825501Medicaid