Provider Demographics
NPI:1417599234
Name:CHARLES W PHILLIPS
Entity Type:Organization
Organization Name:CHARLES W PHILLIPS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:432-689-0323
Mailing Address - Street 1:4311 W WADLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-5457
Mailing Address - Country:US
Mailing Address - Phone:432-689-0323
Mailing Address - Fax:
Practice Address - Street 1:4311 W WADLEY AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-5457
Practice Address - Country:US
Practice Address - Phone:432-689-0323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty