Provider Demographics
NPI:1265564355
Name:DR. LAURA STANCIK, OPTOMETRIST, P. C.
Entity type:Organization
Organization Name:DR. LAURA STANCIK, OPTOMETRIST, P. C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CLIFTON
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:940-692-9696
Mailing Address - Street 1:4210 KELL BLVD
Mailing Address - Street 2:STE 108
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-4813
Mailing Address - Country:US
Mailing Address - Phone:940-692-9696
Mailing Address - Fax:940-692-7303
Practice Address - Street 1:4210 KELL BLVD
Practice Address - Street 2:STE 108
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-4813
Practice Address - Country:US
Practice Address - Phone:940-692-9696
Practice Address - Fax:940-692-7303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5596T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00E30MMedicare PIN
TX0317970001Medicare NSC