=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336359520
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R B MATOCHA OPTOMETRIST INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2007
-----------------------------------------------------
Last Update Date | 03/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2115 BROADWAY ST
-----------------------------------------------------
City | GALVESTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77550-4637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-762-2020
-----------------------------------------------------
Fax | 409-765-6741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2115 BROADWAY ST
-----------------------------------------------------
City | GALVESTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77550-4637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-762-2020
-----------------------------------------------------
Fax | 409-765-6741
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RAY B. MATOCHA
-----------------------------------------------------
Credential | O. D.
-----------------------------------------------------
Telephone | 409-762-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2167T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------