Provider Demographics
NPI:1740256510
Name:MEMORIAL EYE, PA
Entity type:Organization
Organization Name:MEMORIAL EYE, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OD
Authorized Official - Prefix:DR
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOLBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-556-5353
Mailing Address - Street 1:2677 WILCREST DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-3211
Mailing Address - Country:US
Mailing Address - Phone:713-977-1170
Mailing Address - Fax:713-977-3327
Practice Address - Street 1:2677 WILCREST DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-3211
Practice Address - Country:US
Practice Address - Phone:713-977-1170
Practice Address - Fax:713-977-3327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0193799-01Medicaid
TX1127550001Medicare NSC
TX0A4978Medicare PIN