Provider Demographics
NPI:1841574795
Name:SAN ANTONIO LIGHTHOUSE FOR THE BLIND
Entity Type:Organization
Organization Name:SAN ANTONIO LIGHTHOUSE FOR THE BLIND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:N
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-533-5195
Mailing Address - Street 1:2305 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78210-4920
Mailing Address - Country:US
Mailing Address - Phone:210-533-5195
Mailing Address - Fax:210-533-4230
Practice Address - Street 1:2300 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78210-4921
Practice Address - Country:US
Practice Address - Phone:210-533-5195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty