Provider Demographics
NPI:1467657916
Name:PHILLIPS VISION CLINIC LLC
Entity Type:Organization
Organization Name:PHILLIPS VISION CLINIC LLC
Other - Org Name:TEXARKANA EYE ASSOCIATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:903-329-5051
Mailing Address - Street 1:4109 MOORES LN
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2159
Mailing Address - Country:US
Mailing Address - Phone:903-329-5051
Mailing Address - Fax:903-329-5053
Practice Address - Street 1:4504 TEXAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3027
Practice Address - Country:US
Practice Address - Phone:903-792-3705
Practice Address - Fax:903-794-5008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5480T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR98441OtherARKANSAS BLUE CROSS BLUE SHIELD
TX01915611OtherTEXAS MEDICAID
AR140981722Medicaid
TX41046137OtherRAIL ROAD MEDICARE
TX00795EMedicare PIN
AR98441OtherARKANSAS BLUE CROSS BLUE SHIELD
TX01915611OtherTEXAS MEDICAID
AR140981722Medicaid