Provider Demographics
NPI:1306194519
Name:SOUTHERN SKY VISION CENTER
Entity Type:Organization
Organization Name:SOUTHERN SKY VISION CENTER
Other - Org Name:FANT EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:EVENOR
Authorized Official - Last Name:GALDAMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:406-439-1155
Mailing Address - Street 1:2901 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2125
Mailing Address - Country:US
Mailing Address - Phone:903-831-5706
Mailing Address - Fax:903-832-4506
Practice Address - Street 1:2901 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2125
Practice Address - Country:US
Practice Address - Phone:903-831-5706
Practice Address - Fax:903-832-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center