MEDICARE: EYECARE OF TEXAS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	7076TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033367891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYECARE OF TEXAS PC

Provider Business Mailing Address
First Line	:	5025 NW LOOP 410
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-5313
Country	:	US
Telephone Number	:	210-520-0051
Fax Number	:	210-520-0347

Provider Business Practice Location Address
First Line	:	5025 NW LOOP 410
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-5313
Country	:	US
Telephone Number	:	210-520-0051
Fax Number	:	210-520-0347

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JACK WAYNE ROUNTREE JR.
Credential	:	OD
Telephone Number	:	210-520-0051

Provider Enumeration Date	:	09/05/2008
Last Update Date	:	07/13/2022

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Directions to “EYECARE OF TEXAS PC ” Practice Location

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