Provider Demographics
NPI:1316386873
Name:RENAISSANCE EYECARE
Entity Type:Organization
Organization Name:RENAISSANCE EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMERY
Authorized Official - Middle Name:C
Authorized Official - Last Name:HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-905-7197
Mailing Address - Street 1:2080 N HWY 360
Mailing Address - Street 2:STE:125
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-1400
Mailing Address - Country:US
Mailing Address - Phone:817-633-2020
Mailing Address - Fax:214-788-2373
Practice Address - Street 1:1616 W HENDERSON ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4123
Practice Address - Country:US
Practice Address - Phone:817-633-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2519152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280357YRAAMedicare PIN