Provider Demographics
NPI:1245695972
Name:WACO VISION CENTER, PLLC
Entity type:Organization
Organization Name:WACO VISION CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LONG
Authorized Official - Middle Name:
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-262-2145
Mailing Address - Street 1:5836 SUNNY MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8782
Mailing Address - Country:US
Mailing Address - Phone:817-262-2145
Mailing Address - Fax:
Practice Address - Street 1:5201 BOSQUE BLVD
Practice Address - Street 2:#220
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4676
Practice Address - Country:US
Practice Address - Phone:254-741-1022
Practice Address - Fax:254-776-1053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-22
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8143TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328585ZT6CMedicare PIN