Provider Demographics
NPI:1982886040
Name:VISION SOURCE - COPPERFIELD PA
Entity Type:Organization
Organization Name:VISION SOURCE - COPPERFIELD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD, PHD
Authorized Official - Phone:281-933-3446
Mailing Address - Street 1:13615 BELLAIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-1714
Mailing Address - Country:US
Mailing Address - Phone:281-933-3446
Mailing Address - Fax:281-933-6865
Practice Address - Street 1:7603 HIGHWAY 6 NORTH
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095
Practice Address - Country:US
Practice Address - Phone:281-859-8000
Practice Address - Fax:281-859-4507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4042TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty