Provider Demographics
NPI:1124228069
Name:WACO OPTICAL INC
Entity Type:Organization
Organization Name:WACO OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-756-5771
Mailing Address - Street 1:2400 AMBASSADOR DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-9702
Mailing Address - Country:US
Mailing Address - Phone:254-756-5771
Mailing Address - Fax:254-741-1048
Practice Address - Street 1:2400 AMBASSADOR DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-9702
Practice Address - Country:US
Practice Address - Phone:254-756-5771
Practice Address - Fax:254-741-1048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0900800001Medicare ID - Type Unspecified