Healthcare Provider Details

I. General information

NPI: 1609220995
Provider Name (Legal Business Name): OCVT SO CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E SONTERRA BLVD SUITE 100
SAN ANTONIO TX
78258-4075
US

IV. Provider business mailing address

255 E SONTERRA BLVD SUITE 100
SAN ANTONIO TX
78258-4075
US

V. Phone/Fax

Practice location:
  • Phone: 210-490-9900
  • Fax:
Mailing address:
  • Phone: 210-490-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7197T
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number7197
License Number StateTX

VIII. Authorized Official

Name: BRIANA M LARSON
Title or Position: CEO
Credential: D.O.
Phone: 210-490-9900