Healthcare Provider Details

I. General information

NPI: 1508040429
Provider Name (Legal Business Name): EYE COUNTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 NORTH LLANO STREET SUITE A
FREDERICKSBURG TX
78624-5449
US

IV. Provider business mailing address

1102 NORTH LLANO STREET SUITE A
FREDERICKSBURG TX
78624-5449
US

V. Phone/Fax

Practice location:
  • Phone: 830-997-0131
  • Fax: 866-897-9855
Mailing address:
  • Phone: 830-997-0131
  • Fax: 866-897-9855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number4526TG
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4526TG
License Number StateTX

VIII. Authorized Official

Name: MRS. DAWN SMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 830-997-0131