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General NPI Number Information
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NPI Number | 1679869077
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Entity Type | Organization
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Legal Business Name | SOUTHEAST TEXAS OPTICAL, LLC
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Dates
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Enumeration Date | 06/23/2011
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Last Update Date | 09/28/2011
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Provider Practice Location Address
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Address Line | 6420 EASTEX FWY STE B
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City | BEAUMONT
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State | TX
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Zip | 77708-4338
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Country | US
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Telephone | 409-899-2242
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Fax | 409-899-5340
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Provider Business Mailing Address
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Address Line | 6420 EASTEX FWY STE B
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City | BEAUMONT
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State | TX
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Zip | 77708-4338
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Country | US
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Telephone | 409-899-2242
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Fax | 409-899-5340
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Authorized Official
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Title or Position | OWNER / PROVIDER
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Name | DR. ALAN RAY RISING SR.
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Credential | OD
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Telephone | 409-899-2242
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number | 3213TG
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License Number State | TX
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