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General NPI Number Information
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NPI Number | 1891096962
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Entity Type | Organization
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Legal Business Name | ADVANCED VISIONCARE OF FORT WORTH PA
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Dates
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Enumeration Date | 11/05/2010
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Last Update Date | 11/05/2010
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Provider Practice Location Address
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Address Line | 4919 S HULEN ST
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City | FORT WORTH
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State | TX
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Zip | 76132-1407
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Country | US
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Telephone | 817-370-2100
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Fax | 817-539-8035
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Provider Business Mailing Address
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Address Line | 4919 S HULEN ST
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City | FORT WORTH
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State | TX
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Zip | 76132-1407
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Country | US
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Telephone | 817-370-2100
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Fax | 817-539-8035
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Authorized Official
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Title or Position | MANAGER
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Name | JAMES KEVIN SMITH
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Credential |
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Telephone | 817-370-2100
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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 | 4711T
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License Number State | TX
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