Provider Demographics
NPI:1265835482
Name:KELLER VISION CORPORATION
Entity Type:Organization
Organization Name:KELLER VISION CORPORATION
Other - Org Name:APEX EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FORTSMITH
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-766-2090
Mailing Address - Street 1:5860 N TARRANT PKWY
Mailing Address - Street 2:SUITE 108 A
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-7201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5860 N TARRANT PKWY
Practice Address - Street 2:SUITE 108 A
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-7201
Practice Address - Country:US
Practice Address - Phone:817-766-2090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty