MEDICARE: TRINA LIESKE OD PA

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0030FG	OTHER	TX	BCBS PROVIDER #

General Provider Information

NPI Number	:	1609075696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRINA LIESKE OD PA

Provider Business Mailing Address
First Line	:	5412 BOAT CLUB RD STE 150
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-1205
Country	:	US
Telephone Number	:	817-546-9000
Fax Number	:	817-546-1126

Provider Business Practice Location Address
First Line	:	5412 BOAT CLUB RD STE 150
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-1205
Country	:	US
Telephone Number	:	817-546-9000
Fax Number	:	817-546-1126

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TRINA LIESKE
Credential	:	O.D.
Telephone Number	:	817-546-9000

Provider Enumeration Date	:	07/11/2007
Last Update Date	:	12/28/2021

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Directions to “TRINA LIESKE OD PA ” Practice Location

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