Provider Demographics
NPI:1255338612
Name:CLEAR LAKE EYE CENTER LLP
Entity type:Organization
Organization Name:CLEAR LAKE EYE CENTER LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:MICHELETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-526-1600
Mailing Address - Street 1:3100 WESLAYAN
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027
Mailing Address - Country:US
Mailing Address - Phone:713-526-1600
Mailing Address - Fax:713-526-6520
Practice Address - Street 1:1046 HERCULES
Practice Address - Street 2:STE A
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058
Practice Address - Country:US
Practice Address - Phone:281-488-0070
Practice Address - Fax:281-488-0078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0059FAOtherBLUE CROSS BLUE SHIELD
TX4393740001OtherPALMETTO GBA
TX00124SMedicare ID - Type Unspecified
CJ4916Medicare PIN
4393740001Medicare NSC