=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356962666
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POLYANNA DE LA GARZA OPTOMETRIST PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2020
-----------------------------------------------------
Last Update Date | 04/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22438 TOMBALL PARKWAY
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-925-7576
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9322 CHARTER PINE ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-2053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-567-8946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | POLYANNA DE LA GARZA
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 281-925-7576
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------