Provider Demographics
NPI:1619001013
Name:EAST TEXAS OPTICAL, INC
Entity Type:Organization
Organization Name:EAST TEXAS OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:LISKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-878-2451
Mailing Address - Street 1:PO BOX 49
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75783-0049
Mailing Address - Country:US
Mailing Address - Phone:903-878-2451
Mailing Address - Fax:902-878-2933
Practice Address - Street 1:2476 W STATE HIGHWAY 154
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:TX
Practice Address - Zip Code:75783-5587
Practice Address - Country:US
Practice Address - Phone:903-878-2451
Practice Address - Fax:903-878-2933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0929750001Medicare ID - Type Unspecified