Provider Demographics
NPI:1861674111
Name:BOERNE OPTICAL LTD 1
Entity Type:Organization
Organization Name:BOERNE OPTICAL LTD 1
Other - Org Name:TRINITY VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SCANNELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:830-249-3898
Mailing Address - Street 1:1201 S MAIN ST
Mailing Address - Street 2:STE 108
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2833
Mailing Address - Country:US
Mailing Address - Phone:830-249-3898
Mailing Address - Fax:830-249-9228
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:STE 108
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2833
Practice Address - Country:US
Practice Address - Phone:830-249-3898
Practice Address - Fax:830-249-9228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4032TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E90WMedicare PIN