Provider Demographics
NPI:1104037415
Name:ATASCOSA VISION SOURCE,PA
Entity Type:Organization
Organization Name:ATASCOSA VISION SOURCE,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PLANCHET
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:830-569-8771
Mailing Address - Street 1:1514 W OAKLAWN RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:TX
Mailing Address - Zip Code:78064-3830
Mailing Address - Country:US
Mailing Address - Phone:830-569-8771
Mailing Address - Fax:830-569-2346
Practice Address - Street 1:1514 W OAKLAWN RD
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:TX
Practice Address - Zip Code:78064-3830
Practice Address - Country:US
Practice Address - Phone:830-569-8771
Practice Address - Fax:830-569-2346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05681TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00227713OtherPALMETTE GBA RAILROAD MEDIARE
TX164513702Medicaid
TX00298XMedicare PIN
TXU99643Medicare UPIN
TX164513702Medicaid