Healthcare Provider Details

I. General information

NPI: 1619264090
Provider Name (Legal Business Name): ELK VISION HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

886 E LENNON DR STE 102
EMORY TX
75440-3216
US

IV. Provider business mailing address

886 E LENNON DR STE 102
EMORY TX
75440-3216
US

V. Phone/Fax

Practice location:
  • Phone: 903-474-9090
  • Fax: 903-474-9111
Mailing address:
  • Phone: 903-474-9090
  • Fax: 903-474-9111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7878T
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number7878T
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number7878T
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number7878T
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number7878T
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number7878T
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number7878T
License Number StateTX

VIII. Authorized Official

Name: ERIC LEE KETCHUM
Title or Position: OWNER
Credential: O.D.
Phone: 903-474-9090