MEDICARE: PRISTINE VISION PLLC

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	7749	TX

General Provider Information

NPI Number	:	1720526122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRISTINE VISION PLLC

Provider Business Mailing Address
First Line	:	3333 WESLAYAN ST
Second Line	:	UNIT 1223
City	:	HOUSTON
State	:	TX
Zip	:	77027-6359
Country	:	US
Telephone Number	:	832-791-3393
Fax Number	:	832-681-8362

Provider Business Practice Location Address
First Line	:	2700 ELDRIDGE PKWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77082-6870
Country	:	US
Telephone Number	:	832-791-3393
Fax Number	:	832-681-8362

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	AMY LO
Credential	:	O.D.
Telephone Number	:	832-791-3393

Provider Enumeration Date	:	02/06/2017
Last Update Date	:	02/06/2017

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