Provider Demographics
NPI:1578879102
Name:PERMIAN BASIN EYE CARE CENTER LLC
Entity Type:Organization
Organization Name:PERMIAN BASIN EYE CARE CENTER LLC
Other - Org Name:TEXAS COUNTRY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:432-661-6579
Mailing Address - Street 1:2200 W WADLEY AVE
Mailing Address - Street 2:STE 22
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-6438
Mailing Address - Country:US
Mailing Address - Phone:432-684-7287
Mailing Address - Fax:432-684-7297
Practice Address - Street 1:2200 W WADLEY AVE
Practice Address - Street 2:STE 22
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-6438
Practice Address - Country:US
Practice Address - Phone:432-684-7287
Practice Address - Fax:432-684-7297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7598T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty