Provider Demographics
NPI:1770030587
Name:THIRD EYE WOUND CARE, PLLC
Entity type:Organization
Organization Name:THIRD EYE WOUND CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-688-1588
Mailing Address - Street 1:3437 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2718
Mailing Address - Country:US
Mailing Address - Phone:817-688-1588
Mailing Address - Fax:817-423-7361
Practice Address - Street 1:3437 W 7TH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2718
Practice Address - Country:US
Practice Address - Phone:817-688-1588
Practice Address - Fax:817-423-7361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9653207QH0002X, 209800000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No209800000XAllopathic & Osteopathic PhysiciansLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX314993Medicare PIN