Provider Demographics
NPI:1417973280
Name:BATES & HARRIS O D INC
Entity Type:Organization
Organization Name:BATES & HARRIS O D INC
Other - Org Name:TEXAS STATE OPTICAL OF VICTORIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WAKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:361-578-2904
Mailing Address - Street 1:505 E MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2043
Mailing Address - Country:US
Mailing Address - Phone:361-578-2904
Mailing Address - Fax:361-578-7931
Practice Address - Street 1:505 E MOCKINGBIRD LN
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2043
Practice Address - Country:US
Practice Address - Phone:361-578-2904
Practice Address - Fax:361-578-7931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3433T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019365801Medicaid
TX0455360001Medicare NSC
TX00E45GMedicare PIN