=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215542022
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TSO BAY CITY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2020
-----------------------------------------------------
Last Update Date | 11/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4310 7TH ST STE 400
-----------------------------------------------------
City | BAY CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77414-5288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-297-8188
-----------------------------------------------------
Fax | 979-297-5410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 HIGHWAY 332 W STE A5
-----------------------------------------------------
City | LAKE JACKSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77566-4017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-297-8188
-----------------------------------------------------
Fax | 979-297-5410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. DARRIN C. SHANDLEY
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 979-297-8188
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------