Provider Demographics
NPI:1427228964
Name:TRUSSELL THANE OD
Entity Type:Organization
Organization Name:TRUSSELL THANE OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:THANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-773-2083
Mailing Address - Street 1:1501 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:TX
Mailing Address - Zip Code:79553-6832
Mailing Address - Country:US
Mailing Address - Phone:325-773-2083
Mailing Address - Fax:325-773-2526
Practice Address - Street 1:1501 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:TX
Practice Address - Zip Code:79553-6832
Practice Address - Country:US
Practice Address - Phone:325-773-2083
Practice Address - Fax:325-773-2526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4720TG332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E04TMedicare PIN
TX0871620001Medicare NSC
TXU32283Medicare UPIN