Provider Demographics
NPI:1063639698
Name:CHAMPIONS EYECARE PC
Entity Type:Organization
Organization Name:CHAMPIONS EYECARE PC
Other - Org Name:TEXAS STATE OPTICAL OF CHAMPIONS VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MALTZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-440-5887
Mailing Address - Street 1:5774 FM 1960 RD W
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77069-4204
Mailing Address - Country:US
Mailing Address - Phone:281-440-5887
Mailing Address - Fax:281-440-0368
Practice Address - Street 1:5774 FM 1960 RD W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77069-4204
Practice Address - Country:US
Practice Address - Phone:281-440-5887
Practice Address - Fax:281-440-0368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2671T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDP3464OtherRAILROAD MEDICARE PTAN
TXP00749723OtherRAILROAD MEDICARE
TXDP3464OtherRAILROAD MEDICARE PTAN
TXDP3464OtherRAILROAD MEDICARE PTAN
TX00389WMedicare PIN