=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457350605
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY N HOLDRIDGE O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1980 E NORTHWEST PKWY
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-6510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-329-2700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 761 TRAILS END CIR
-----------------------------------------------------
City | HURST
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76054-6020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-428-3575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 06588TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------