Provider Demographics
NPI:1386660942
Name:EAST TEXAS EYE CARE ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:EAST TEXAS EYE CARE ASSOCIATES, PLLC
Other - Org Name:THE OPTICAL SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-595-0500
Mailing Address - Street 1:2440 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-3525
Mailing Address - Country:US
Mailing Address - Phone:903-595-0500
Mailing Address - Fax:903-595-1212
Practice Address - Street 1:608 MARYLAND DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3332
Practice Address - Country:US
Practice Address - Phone:903-675-6440
Practice Address - Fax:903-675-6676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085828404Medicaid
TX1259330005Medicare NSC