Provider Demographics
NPI:1104003581
Name:CHILDRESS VISION CLINIC
Entity Type:Organization
Organization Name:CHILDRESS VISION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:CHILDRESS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:903-753-4436
Mailing Address - Street 1:408 E MAGRILL ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6444
Mailing Address - Country:US
Mailing Address - Phone:903-753-4436
Mailing Address - Fax:903-757-4400
Practice Address - Street 1:408 E MAGRILL ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6444
Practice Address - Country:US
Practice Address - Phone:903-753-4436
Practice Address - Fax:903-757-4400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1892152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E14JMedicare PIN