=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598190381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIM PHAM CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2013
-----------------------------------------------------
Last Update Date | 02/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 HIGHWAY 157 N
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-3921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-518-8018
-----------------------------------------------------
Fax | 682-518-8017
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2271
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-0047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-793-2959
-----------------------------------------------------
Fax | 682-518-8017
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KIM PHAM
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 817-793-2959
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 8070T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------