Provider Demographics
NPI:1336326966
Name:COLLEYVILLE VISION ASSOCIATES
Entity Type:Organization
Organization Name:COLLEYVILLE VISION ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-428-0400
Mailing Address - Street 1:1213 HALL JOHNSON RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5847
Mailing Address - Country:US
Mailing Address - Phone:817-428-0400
Mailing Address - Fax:
Practice Address - Street 1:1213 HALL JOHNSON RD
Practice Address - Street 2:SUITE 300
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5847
Practice Address - Country:US
Practice Address - Phone:817-428-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3802TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6610980001Medicare NSC
TX00702WMedicare PIN
TXT13769Medicare UPIN