Provider Demographics
NPI:1033549555
Name:EPIC VISION CENTER PLLC
Entity Type:Organization
Organization Name:EPIC VISION CENTER PLLC
Other - Org Name:EPIC VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:210-858-7408
Mailing Address - Street 1:9262 CULEBRA RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-3571
Mailing Address - Country:US
Mailing Address - Phone:210-647-4733
Mailing Address - Fax:210-647-4741
Practice Address - Street 1:9262 CULEBRA RD STE 106
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-3574
Practice Address - Country:US
Practice Address - Phone:210-647-4733
Practice Address - Fax:210-647-4741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7055T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX340583901Medicaid