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General NPI Number Information
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NPI Number | 1104093335
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Entity Type | Organization
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Legal Business Name | BRAZOS PROF. OPT.
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Dates
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Enumeration Date | 05/15/2008
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Last Update Date | 07/29/2008
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Provider Practice Location Address
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Address Line | 2901 E 29TH ST STE 105
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City | BRYAN
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State | TX
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Zip | 77802-2691
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Country | US
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Telephone | 979-776-7111
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Fax | 979-776-7112
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Provider Business Mailing Address
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Address Line | 2901 E 29TH ST STE 105
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City | BRYAN
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State | TX
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Zip | 77802-2691
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Country | US
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Telephone | 979-776-7111
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Fax | 979-776-7112
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Authorized Official
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Title or Position | OWNER
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Name | MR. LESTER A PROVE
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Credential |
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Telephone | 979-776-7111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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