Provider Demographics
NPI:1508920570
Name:KERRVILLE EYE CENTER PA
Entity Type:Organization
Organization Name:KERRVILLE EYE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-257-4417
Mailing Address - Street 1:PO BOX 294869
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78029-4869
Mailing Address - Country:US
Mailing Address - Phone:830-257-4417
Mailing Address - Fax:830-257-1480
Practice Address - Street 1:1001 WATER ST
Practice Address - Street 2:STE E100
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-3523
Practice Address - Country:US
Practice Address - Phone:830-257-4417
Practice Address - Fax:830-257-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6394174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0010GHOtherBCBS GROUP #
TX143576001Medicaid
TX0010GHOtherBCBS GROUP #