Provider Demographics
NPI:1912166455
Name:FIVE POINTS OPTICAL CENTER
Entity Type:Organization
Organization Name:FIVE POINTS OPTICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VAUGHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-241-9357
Mailing Address - Street 1:4101 US HIGHWAY 77
Mailing Address - Street 2:STE B3
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-4542
Mailing Address - Country:US
Mailing Address - Phone:361-241-9357
Mailing Address - Fax:361-241-4461
Practice Address - Street 1:4101 US HIGHWAY 77
Practice Address - Street 2:STE B3
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-4542
Practice Address - Country:US
Practice Address - Phone:361-241-9357
Practice Address - Fax:361-241-4461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02183TG332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093320201Medicaid
TXT16707Medicare UPIN
TX0659640001Medicare NSC