Provider Demographics
NPI:1891952594
Name:PENA OPTICAL SOLUTIONS LLC
Entity Type:Organization
Organization Name:PENA OPTICAL SOLUTIONS LLC
Other - Org Name:TEXAS STATE OPTICAL KERRVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY
Authorized Official - Prefix:
Authorized Official - First Name:BENITO
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:830-257-6336
Mailing Address - Street 1:500 JUNCTION HWY
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5065
Mailing Address - Country:US
Mailing Address - Phone:830-257-6336
Mailing Address - Fax:830-792-4808
Practice Address - Street 1:500 JUNCTION HWY
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5065
Practice Address - Country:US
Practice Address - Phone:830-257-6336
Practice Address - Fax:830-792-4808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7139TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7139TGOtherOPTOMETRY LICENSE
TX=========OtherTAX IDENTIFICATION NUMBER