Provider Demographics
NPI:1902011398
Name:360 VISION PC
Entity Type:Organization
Organization Name:360 VISION PC
Other - Org Name:NORTHWEST HILLS EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:512-328-0555
Mailing Address - Street 1:3808 SPICEWOOD SPRINGS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8964
Mailing Address - Country:US
Mailing Address - Phone:512-328-0555
Mailing Address - Fax:512-340-0009
Practice Address - Street 1:3808 SPICEWOOD SPRINGS RD STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8964
Practice Address - Country:US
Practice Address - Phone:512-328-0555
Practice Address - Fax:512-340-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5146TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0195224-01Medicaid
00E82TMedicare PIN
TX00E82TMedicare ID - Type Unspecified
TX0195224-01Medicaid