=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043606197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTICAL EDGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2015
-----------------------------------------------------
Last Update Date | 12/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14870 SPACE CENTER BLVD SUITE H
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77062-2368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-984-7515
-----------------------------------------------------
Fax | 855-751-5551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14870 SPACE CENTER BLVD SUITE H
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77062-2368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | REGINA THUY VY NGUYEN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 281-984-7515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 7262TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------