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General NPI Number Information
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NPI Number | 1124672225
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Entity Type | Organization
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Legal Business Name | BAY AREA OPTOMETRY GROUP
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Dates
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Enumeration Date | 07/26/2019
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Last Update Date | 07/16/2020
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Provider Practice Location Address
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Address Line | 3457 CLEAR LAKE CITY BLVD # 500
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City | HOUSTON
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State | TX
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Zip | 77059-2516
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Country | US
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Telephone | 281-910-4604
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Fax |
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Provider Business Mailing Address
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Address Line | 6106 TIMBERMOSS CT
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City | LEAGUE CITY
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State | TX
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Zip | 77573-2592
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Country | US
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Telephone | 281-910-4604
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JOSHUA RYAN DEVERA
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Credential | OD
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Telephone | 281-910-4604
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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