Provider Demographics
NPI:1689041634
Name:ROANOKE VISION ASSOCIATES
Entity Type:Organization
Organization Name:ROANOKE VISION ASSOCIATES
Other - Org Name:VISION SOURCE TROPHY CLUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:469-464-5949
Mailing Address - Street 1:301 TROPHY LAKE DR
Mailing Address - Street 2:STE 128
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5238
Mailing Address - Country:US
Mailing Address - Phone:682-237-2103
Mailing Address - Fax:682-803-0559
Practice Address - Street 1:856 E HIGHWAY 114 STE 100
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262-6790
Practice Address - Country:US
Practice Address - Phone:682-237-2103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8216152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty