Healthcare Provider Details

I. General information

NPI: 1649548447
Provider Name (Legal Business Name): ENCLAVE VISION ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 ELDRIDGE PKWY STE 120
HOUSTON TX
77077-2543
US

IV. Provider business mailing address

1140 ELDRIDGE PKWY STE 120
HOUSTON TX
77077-2543
US

V. Phone/Fax

Practice location:
  • Phone: 713-410-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7712TG
License Number StateTX

VIII. Authorized Official

Name: BRANDI N MONTGOMERY
Title or Position: OWNER
Credential: O.D.
Phone: 806-676-1713