Healthcare Provider Details

I. General information

NPI: 1376828756
Provider Name (Legal Business Name): VI TAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 LAKE WOODLANDS DR SUITE 300
SPRING TX
77380-5000
US

IV. Provider business mailing address

1201 LAKE WOODLANDS DR SUITE 300
SPRING TX
77380-5000
US

V. Phone/Fax

Practice location:
  • Phone: 281-292-2720
  • Fax: 281-362-0442
Mailing address:
  • Phone: 281-292-2720
  • Fax: 281-362-0442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7874TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: