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General NPI Number Information
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NPI Number | 1689041634
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Entity Type | Organization
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Legal Business Name | ROANOKE VISION ASSOCIATES
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Dates
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Enumeration Date | 08/25/2015
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Last Update Date | 12/01/2020
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Provider Practice Location Address
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Address Line | 856 E HIGHWAY 114 STE 100
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City | ROANOKE
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State | TX
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Zip | 76262-6790
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Country | US
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Telephone | 682-237-2103
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Fax |
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Provider Business Mailing Address
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Address Line | 301 TROPHY LAKE DR STE 128
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City | TROPHY CLUB
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State | TX
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Zip | 76262-5238
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Country | US
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Telephone | 682-237-2103
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Fax | 682-803-0559
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Authorized Official
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Title or Position | PRESIDENT
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Name | KELVIN LAM
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Credential | OD
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Telephone | 469-464-5949
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 8216
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License Number State | TX
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