Provider Demographics
NPI:1710172333
Name:WALLER FAMILY EYECARE
Entity Type:Organization
Organization Name:WALLER FAMILY EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:936-372-3644
Mailing Address - Street 1:31315 FM 2920 RD
Mailing Address - Street 2:SUITE 19
Mailing Address - City:WALLER
Mailing Address - State:TX
Mailing Address - Zip Code:77484-8049
Mailing Address - Country:US
Mailing Address - Phone:936-372-3644
Mailing Address - Fax:936-372-3243
Practice Address - Street 1:31315 FM 2920 RD
Practice Address - Street 2:SUITE 19
Practice Address - City:WALLER
Practice Address - State:TX
Practice Address - Zip Code:77484-8049
Practice Address - Country:US
Practice Address - Phone:936-372-3644
Practice Address - Fax:936-372-3243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6241TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173420401Medicaid
00900YMedicare PIN
TX5449870001Medicare NSC