Provider Demographics
NPI:1871655118
Name:SOUTH SHORE EYE CENTER LLC
Entity Type:Organization
Organization Name:SOUTH SHORE EYE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-334-5277
Mailing Address - Street 1:2951 MARINA BAY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2735
Mailing Address - Country:US
Mailing Address - Phone:281-334-5277
Mailing Address - Fax:281-334-1633
Practice Address - Street 1:2951 MARINA BAY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2735
Practice Address - Country:US
Practice Address - Phone:281-334-5277
Practice Address - Fax:281-334-1633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4177TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX270334Medicare PIN