=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104957257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 20-20 VISION CLINIC, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2007
-----------------------------------------------------
Last Update Date | 07/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 819 IRA E WOODS AVE
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-488-4893
-----------------------------------------------------
Fax | 817-488-5939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 819 IRA E WOODS AVE
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-488-4893
-----------------------------------------------------
Fax | 817-488-5939
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | JERRY L LATHAM
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 817-488-4893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------