=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619001013
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST TEXAS OPTICAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2476 W STATE HIGHWAY 154
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75783-5587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-878-2451
-----------------------------------------------------
Fax | 903-878-2933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 49
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75783-0049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-878-2451
-----------------------------------------------------
Fax | 902-878-2933
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RICHARD EDWARD LISKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-878-2451
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------