Provider Demographics
NPI:1679869077
Name:SOUTHEAST TEXAS OPTICAL, LLC
Entity Type:Organization
Organization Name:SOUTHEAST TEXAS OPTICAL, LLC
Other - Org Name:EYE GEAR WAREHOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:RISING
Authorized Official - Suffix:SR
Authorized Official - Credentials:OD
Authorized Official - Phone:409-899-2242
Mailing Address - Street 1:6420 EASTEX FWY
Mailing Address - Street 2:STE B
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77708-4338
Mailing Address - Country:US
Mailing Address - Phone:409-899-2242
Mailing Address - Fax:409-899-5340
Practice Address - Street 1:6420 EASTEX FWY
Practice Address - Street 2:STE B
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77708-4338
Practice Address - Country:US
Practice Address - Phone:409-899-2242
Practice Address - Fax:409-899-5340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-23
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3213TG152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB133665Medicare PIN