Provider Demographics
NPI:1205881935
Name:HERITAGE EYE CENTER LC
Entity type:Organization
Organization Name:HERITAGE EYE CENTER LC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:1501-B REDBUD BLVD
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069
Mailing Address - Country:US
Mailing Address - Phone:972-548-0771
Mailing Address - Fax:972-562-2300
Practice Address - Street 1:1501-B REDBUD BLVD
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069
Practice Address - Country:US
Practice Address - Phone:972-548-0771
Practice Address - Fax:972-562-2300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000253261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085907601Medicaid
TX451092Medicare ID - Type UnspecifiedMEDICARE