=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548042138
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE HERITAGE EYECARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2023
-----------------------------------------------------
Last Update Date | 10/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9555 HARMON RD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76177-7517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-757-9271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1485 PRIMROSE PL
-----------------------------------------------------
City | HASLET
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76052-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-757-9271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/OWNER
-----------------------------------------------------
Name | DR. BARJINDER SINGH GILL
-----------------------------------------------------
Credential | O.D
-----------------------------------------------------
Telephone | 817-757-9271
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------