Provider Demographics
NPI:1750627188
Name:EYE RISE CLINIC
Entity type:Organization
Organization Name:EYE RISE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-549-8025
Mailing Address - Street 1:2928 BRITTLEBUSH DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-2388
Mailing Address - Country:US
Mailing Address - Phone:682-430-1487
Mailing Address - Fax:
Practice Address - Street 1:6760 WESTWORTH BLVD
Practice Address - Street 2:
Practice Address - City:WESTWORTH VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:76114-4002
Practice Address - Country:US
Practice Address - Phone:682-430-1487
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7498152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty