Provider Demographics
NPI:1841470838
Name:VICTORIA FAMILY EYECARE, PLLC
Entity type:Organization
Organization Name:VICTORIA FAMILY EYECARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:361-570-2010
Mailing Address - Street 1:3804 JOHN STOCKBAUER DR
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2448
Mailing Address - Country:US
Mailing Address - Phone:361-570-2010
Mailing Address - Fax:361-570-2012
Practice Address - Street 1:3804 JOHN STOCKBAUER DR
Practice Address - Street 2:SUITE A-2
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2448
Practice Address - Country:US
Practice Address - Phone:361-570-2010
Practice Address - Fax:361-570-2012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05649T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5649TOtherTEXAS OPTOMETRY LICENSE
TX=========OtherTAX IDENTIFICATION NUMBER
TX00Y306Medicare PIN