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General NPI Number Information
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NPI Number | 1275715963
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Entity Type | Organization
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Legal Business Name | TEXAS STATE OPTICAL OF BRYAN PC
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Dates
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Enumeration Date | 12/04/2007
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Last Update Date | 10/03/2008
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Provider Practice Location Address
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Address Line | 3030 E 29TH ST SUITE 106
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City | BRYAN
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State | TX
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Zip | 77802-2757
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Country | US
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Telephone | 979-731-8446
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Fax |
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Provider Business Mailing Address
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Address Line | 3030 E 29TH ST SUITE 106
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City | BRYAN
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State | TX
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Zip | 77802-2757
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DOCTOR
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Name | GERALD D PHILLIPS
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Credential |
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Telephone | 979-731-8446
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State | TX
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