Healthcare Provider Details

I. General information

NPI: 1972130862
Provider Name (Legal Business Name): BLACKWELDER OPTOMETRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 MANCHACA RD STE B
AUSTIN TX
78748-3786
US

IV. Provider business mailing address

12000 MANCHACA RD STE B
AUSTIN TX
78748-3786
US

V. Phone/Fax

Practice location:
  • Phone: 512-358-8200
  • Fax: 512-358-0376
Mailing address:
  • Phone: 512-358-8200
  • Fax: 512-358-0376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: SARAH BLACKWELDER
Title or Position: OWNER
Credential: OD
Phone: 949-636-0121