MEDICARE: EAGLE EYE CENTER BELLAIRE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	6480TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6480TG	OTHER	TX	TEXAS OPTOMETRY LICENSE

General Provider Information

NPI Number	:	1558645879
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE EYE CENTER BELLAIRE LLC

Provider Business Mailing Address
First Line	:	9188 BELLAIRE BLVD
Second Line	:	SUITE 1
City	:	HOUSTON
State	:	TX
Zip	:	77036-4623
Country	:	US
Telephone Number	:	713-270-9188
Fax Number	:	713-271-9188

Provider Business Practice Location Address
First Line	:	9188 BELLAIRE BLVD
Second Line	:	SUITE 1
City	:	HOUSTON
State	:	TX
Zip	:	77036-4623
Country	:	US
Telephone Number	:	713-270-9188
Fax Number	:	713-271-9188

Authorized Official
Title or Position	:	OWNER
Name	:	YAQUN BAO
Credential	:	OD
Telephone Number	:	713-270-9188

Provider Enumeration Date	:	10/05/2011
Last Update Date	:	10/05/2011

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