Provider Demographics
NPI:1063650430
Name:FORT WORTH EYE ASSOCIATES
Entity Type:Organization
Organization Name:FORT WORTH EYE ASSOCIATES
Other - Org Name:CAMP BOWIE OPTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:H. WILLLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RANELLE
Authorized Official - Suffix:X
Authorized Official - Credentials:DO
Authorized Official - Phone:817-732-9307
Mailing Address - Street 1:5000 COLLINWOOD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TEXAS
Mailing Address - Zip Code:76107
Mailing Address - Country:UM
Mailing Address - Phone:817-732-9307
Mailing Address - Fax:817-732-5499
Practice Address - Street 1:5000 COLLINWOOD AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-3606
Practice Address - Country:US
Practice Address - Phone:817-732-9307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORT WORTH EYE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-23
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0670240001Medicare NSC