=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073047734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISION SOURCE - CHAMBERS TOWN CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2017
-----------------------------------------------------
Last Update Date | 04/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8804 N HIGHWAY 146 SUITE #130
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77523-9022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-543-5245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8804 N HIGHWAY 146 SUITE #130
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77523-9022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-543-5245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEVEN H LAI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-543-5245
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------