Provider Demographics
NPI:1104093335
Name:BRAZOS PROF. OPT.
Entity type:Organization
Organization Name:BRAZOS PROF. OPT.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LESTER
Authorized Official - Middle Name:A
Authorized Official - Last Name:PROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-776-7111
Mailing Address - Street 1:2901 E 29TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2691
Mailing Address - Country:US
Mailing Address - Phone:979-776-7111
Mailing Address - Fax:979-776-7112
Practice Address - Street 1:2901 E 29TH ST STE 105
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2691
Practice Address - Country:US
Practice Address - Phone:979-776-7111
Practice Address - Fax:979-776-7112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX09779001Medicaid
TX0916860001Medicare PIN
TX09779001Medicaid