Provider Demographics
NPI:1083814610
Name:CYNTHIA LACY-STALLWORTH, O.D. LLC
Entity Type:Organization
Organization Name:CYNTHIA LACY-STALLWORTH, O.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LACY-STALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:713-734-5376
Mailing Address - Street 1:1615 S LOOP W
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-4814
Mailing Address - Country:US
Mailing Address - Phone:713-796-2216
Mailing Address - Fax:713-383-7612
Practice Address - Street 1:1615 S LOOP W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-4814
Practice Address - Country:US
Practice Address - Phone:713-796-2216
Practice Address - Fax:713-383-7612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06786T261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01560081Medicaid
PA01560081Medicaid