Provider Demographics
NPI:1467501973
Name:BENBROOK FAMILY VISION CARE PA
Entity Type:Organization
Organization Name:BENBROOK FAMILY VISION CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:G
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-249-8860
Mailing Address - Street 1:114 SPROLES DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76126-3249
Mailing Address - Country:US
Mailing Address - Phone:817-249-8860
Mailing Address - Fax:817-249-8861
Practice Address - Street 1:114 SPROLES DR
Practice Address - Street 2:SUITE 102
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76126-3249
Practice Address - Country:US
Practice Address - Phone:817-249-8860
Practice Address - Fax:817-249-8861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6145830001Medicare NSC