Healthcare Provider Details

I. General information

NPI: 1053974741
Provider Name (Legal Business Name): TRINA LIESKE O.D., FCOVD, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5412 BOAT CLUB RD STE 100
FORT WORTH TX
76135-1206
US

IV. Provider business mailing address

4257 SAN SIMEON LN
FORT WORTH TX
76179-6803
US

V. Phone/Fax

Practice location:
  • Phone: 817-546-9000
  • Fax:
Mailing address:
  • Phone: 817-456-4031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. KATRINA LIESKE
Title or Position: OWNER
Credential: OD
Phone: 817-271-8563