Provider Demographics
NPI:1437272804
Name:VANCLEAVE, ROBERT STEVEN (MANAGER)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:STEVEN
Last Name:VANCLEAVE
Suffix:
Gender:M
Credentials:MANAGER
Other - Prefix:
Other - First Name:BRETTLY
Other - Middle Name:JOEL
Other - Last Name:TEAGUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1750 PINE ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-3044
Mailing Address - Country:US
Mailing Address - Phone:325-670-0500
Mailing Address - Fax:325-676-0593
Practice Address - Street 1:1750 PINE ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-3044
Practice Address - Country:US
Practice Address - Phone:325-670-0500
Practice Address - Fax:325-676-0593
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF29292Medicare UPIN
TXG25851Medicare UPIN
TXD87452Medicare UPIN
TX1259130001Medicare NSC
TXC21075Medicare UPIN