Provider Demographics
NPI:1407213945
Name:TRAVIS STREET OPTICAL, PLLC
Entity Type:Organization
Organization Name:TRAVIS STREET OPTICAL, PLLC
Other - Org Name:TRAVIS STREET OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NELMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-893-8306
Mailing Address - Street 1:PO BOX 1151
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75091-1151
Mailing Address - Country:US
Mailing Address - Phone:903-893-8306
Mailing Address - Fax:903-891-3443
Practice Address - Street 1:1405 N TRAVIS ST
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-3757
Practice Address - Country:US
Practice Address - Phone:903-893-8306
Practice Address - Fax:903-891-3443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5593TG152W00000X
TX5148TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0194EMedicare UPIN
TX00E19ZMedicare UPIN