=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285979310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NTG VISION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2012
-----------------------------------------------------
Last Update Date | 01/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6502 GARTH RD SUITE 200A
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-230-5126
-----------------------------------------------------
Fax | 346-230-5127
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6502 GARTH RD SUITE 200A
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-230-5126
-----------------------------------------------------
Fax | 346-230-5127
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTOMETRIST
-----------------------------------------------------
Name | DR. NICOLETTE T. GILMORE
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 281-421-0599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------