Provider Demographics
NPI:1063546414
Name:COLLEYVILLE EYE CORPORATION
Entity type:Organization
Organization Name:COLLEYVILLE EYE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FORTSMITH
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-485-3300
Mailing Address - Street 1:5307 COLLEYVILLE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5307 COLLEYVILLE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5832
Practice Address - Country:US
Practice Address - Phone:817-485-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty