Provider Demographics
NPI:1265617336
Name:FUNKHOUSER OPTICIANS
Entity type:Organization
Organization Name:FUNKHOUSER OPTICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:FUNKHOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-677-1985
Mailing Address - Street 1:PO BOX 952
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-0952
Mailing Address - Country:US
Mailing Address - Phone:903-677-1985
Mailing Address - Fax:903-677-2099
Practice Address - Street 1:1206 S PALESTINE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3619
Practice Address - Country:US
Practice Address - Phone:903-677-1985
Practice Address - Fax:903-677-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
528354OtherBCBS OF TX
TX066298301Medicaid
TX149257101Medicaid
TX149257101Medicaid