Provider Demographics
NPI:1417170390
Name:PRIMARY EYE CARE CENTER I, LLP
Entity Type:Organization
Organization Name:PRIMARY EYE CARE CENTER I, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CORREALE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-331-8681
Mailing Address - Street 1:2800 S GORDON ST
Mailing Address - Street 2:
Mailing Address - City:ALVIN
Mailing Address - State:TX
Mailing Address - Zip Code:77511-4731
Mailing Address - Country:US
Mailing Address - Phone:281-331-8681
Mailing Address - Fax:281-585-4582
Practice Address - Street 1:2800 S GORDON ST
Practice Address - Street 2:
Practice Address - City:ALVIN
Practice Address - State:TX
Practice Address - Zip Code:77511-4731
Practice Address - Country:US
Practice Address - Phone:281-331-8681
Practice Address - Fax:281-585-4582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4245TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146053701Medicaid
TX00114SMedicare ID - Type UnspecifiedGROUP NUMBER
TX4404480001Medicare NSC