Provider Demographics
NPI:1255083994
Name:W2020 VISION-DT, LLC
Entity type:Organization
Organization Name:W2020 VISION-DT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:LAMAR
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:210-392-4567
Mailing Address - Street 1:12702 TOEPPERWEIN RD STE 209
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3250
Mailing Address - Country:US
Mailing Address - Phone:210-570-5302
Mailing Address - Fax:210-957-7242
Practice Address - Street 1:12702 TOEPPERWEIN RD STE 209
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3250
Practice Address - Country:US
Practice Address - Phone:210-570-5302
Practice Address - Fax:210-957-7242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory