Provider Demographics
NPI:1467819730
Name:TEXARKANA EYE ASSOCIATES-BROKEN BOW BRANCH
Entity Type:Organization
Organization Name:TEXARKANA EYE ASSOCIATES-BROKEN BOW BRANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:903-838-0783
Mailing Address - Street 1:2703 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2328
Mailing Address - Country:US
Mailing Address - Phone:903-838-0783
Mailing Address - Fax:
Practice Address - Street 1:511 S PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-5329
Practice Address - Country:US
Practice Address - Phone:580-584-3434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-18
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty