Provider Demographics
NPI: | 1497231435 |
---|---|
Name: | SEABROOK EYE CENTER PLLC |
Entity Type: | Organization |
Organization Name: | SEABROOK EYE CENTER PLLC |
Other - Org Name: | SEABROOK EYE CENTER |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | ELLEN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | FANDRY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | OD |
Authorized Official - Phone: | 832-753-4073 |
Mailing Address - Street 1: | 603 KIRBY RD |
Mailing Address - Street 2: | |
Mailing Address - City: | SEABROOK |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 77586-5202 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 832-753-4073 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 603 KIRBY RD |
Practice Address - Street 2: | |
Practice Address - City: | SEABROOK |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77586-5202 |
Practice Address - Country: | US |
Practice Address - Phone: | 832-753-4073 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-07-12 |
Last Update Date: | 2020-10-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 8948T.G | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Single Specialty |