Provider Demographics
NPI:1891096962
Name:ADVANCED VISIONCARE OF FORT WORTH PA
Entity Type:Organization
Organization Name:ADVANCED VISIONCARE OF FORT WORTH PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-370-2100
Mailing Address - Street 1:4919 S HULEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-1407
Mailing Address - Country:US
Mailing Address - Phone:817-370-2100
Mailing Address - Fax:817-539-8035
Practice Address - Street 1:4919 S HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-1407
Practice Address - Country:US
Practice Address - Phone:817-370-2100
Practice Address - Fax:817-539-8035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4711T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty