Provider Demographics
NPI:1225210792
Name:CHARLES R SANDERS
Entity Type:Organization
Organization Name:CHARLES R SANDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JO
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-854-2192
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75653-0337
Mailing Address - Country:US
Mailing Address - Phone:903-854-2192
Mailing Address - Fax:903-854-2407
Practice Address - Street 1:1400 LOWES BLVD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-5201
Practice Address - Country:US
Practice Address - Phone:254-200-1165
Practice Address - Fax:254-637-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2907TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG000E15P8Medicaid
TX00E07MMedicare PIN