Provider Demographics
NPI:1083798342
Name:KELVIN VAN VOORST, OD AND STACIE HOUGHTALEN, OD, PA
Entity Type:Organization
Organization Name:KELVIN VAN VOORST, OD AND STACIE HOUGHTALEN, OD, PA
Other - Org Name:PROSPER FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:VAN VOORST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-347-2004
Mailing Address - Street 1:110 NORTH PRESTON ROAD
Mailing Address - Street 2:SUITE 30
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-8794
Mailing Address - Country:US
Mailing Address - Phone:972-347-2004
Mailing Address - Fax:972-347-3847
Practice Address - Street 1:110 NORTH PRESTON ROAD
Practice Address - Street 2:SUITE 30
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8794
Practice Address - Country:US
Practice Address - Phone:972-347-2004
Practice Address - Fax:972-347-3847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6563TG152W00000X
TX6554TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1255350740OtherNPI-STACIE VAN VOORST, OD
TX1396764882OtherNPI-KELVIN VAN VOORST, OD
TXV02131Medicare UPIN
TX00928ZMedicare ID - Type UnspecifiedGROUP NUMBER
TX1255350740OtherNPI-STACIE VAN VOORST, OD
TX1396764882OtherNPI-KELVIN VAN VOORST, OD