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General NPI Number Information
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NPI Number | 1619264090
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Entity Type | Organization
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Legal Business Name | ELK VISION HOLDINGS LLC
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Dates
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Enumeration Date | 07/06/2011
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Last Update Date | 07/06/2011
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Provider Practice Location Address
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Address Line | 886 E LENNON DR STE 102
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City | EMORY
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State | TX
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Zip | 75440-3216
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Country | US
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Telephone | 903-474-9090
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Fax | 903-474-9111
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Provider Business Mailing Address
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Address Line | 886 E LENNON DR STE 102
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City | EMORY
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State | TX
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Zip | 75440-3216
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Country | US
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Telephone | 903-474-9090
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Fax | 903-474-9111
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Authorized Official
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Title or Position | OWNER
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Name | ERIC LEE KETCHUM
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Credential | O.D.
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Telephone | 903-474-9090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 7878T
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 152WL0500X
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Taxonomy Name | Low Vision Rehabilitation Optometrist
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License Number | 7878T
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 152WP0200X
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Taxonomy Name | Pediatric Optometrist
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License Number | 7878T
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License Number State | TX
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Taxonomy #4
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Taxonomy Code | 152WS0006X
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Taxonomy Name | Sports Vision Optometrist
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License Number | 7878T
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License Number State | TX
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Taxonomy #5
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number | 7878T
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License Number State | TX
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Taxonomy #6
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Taxonomy Code | 152WX0102X
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Taxonomy Name | Occupational Vision Optometrist
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License Number | 7878T
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License Number State | TX
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Taxonomy #7
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 7878T
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License Number State | TX
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