Provider Demographics
NPI:1073582466
Name:WILLOWBROOK TSO PC
Entity Type:Organization
Organization Name:WILLOWBROOK TSO PC
Other - Org Name:WILLOWBROOK TEXAS STATE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-412-7842
Mailing Address - Street 1:1250 UVALDE RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-3708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17776 TOMBALL PKWY
Practice Address - Street 2:SUITE #15
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77064-1016
Practice Address - Country:US
Practice Address - Phone:281-890-8480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1573727-01Medicaid
TX1573727-01Medicaid