MEDICARE: VISION SOURCE - COPPERFIELD PA

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	4042TG	TX

General Provider Information

NPI Number	:	1982886040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISION SOURCE - COPPERFIELD PA

Provider Business Mailing Address
First Line	:	13615 BELLAIRE BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-1714
Country	:	US
Telephone Number	:	281-933-3446
Fax Number	:	281-933-6865

Provider Business Practice Location Address
First Line	:	7603 HIGHWAY 6 NORTH
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77095
Country	:	US
Telephone Number	:	281-859-8000
Fax Number	:	281-859-4507

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRUCE WICK
Credential	:	OD, PHD
Telephone Number	:	281-933-3446

Provider Enumeration Date	:	11/30/2007
Last Update Date	:	11/30/2007

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