Provider Demographics
NPI:1265923361
Name:BOERNE EYES ON MAIN PLLC
Entity type:Organization
Organization Name:BOERNE EYES ON MAIN PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:210-861-2011
Mailing Address - Street 1:1365 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2821
Mailing Address - Country:US
Mailing Address - Phone:210-861-2011
Mailing Address - Fax:
Practice Address - Street 1:1365 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006
Practice Address - Country:US
Practice Address - Phone:210-392-1727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-23
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9411T152WL0500X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty