Provider Demographics
NPI:1265564769
Name:VISION SOURCE - KINGWOOD, PA
Entity type:Organization
Organization Name:VISION SOURCE - KINGWOOD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ELLISOR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:713-995-0042
Mailing Address - Street 1:1714 KINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-3046
Mailing Address - Country:US
Mailing Address - Phone:713-995-0042
Mailing Address - Fax:713-995-0548
Practice Address - Street 1:1714 KINGWOOD DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3046
Practice Address - Country:US
Practice Address - Phone:713-995-0042
Practice Address - Fax:713-995-0548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-10
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03337TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0046FEOtherBLUE CROSS & BLUE SHIELD
TX0046FEOtherBLUE CROSS & BLUE SHIELD