Provider Demographics
NPI:1104335918
Name:KILGORE-GILMER-EYE CARE CENTERS P.A.
Entity type:Organization
Organization Name:KILGORE-GILMER-EYE CARE CENTERS P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-983-2020
Mailing Address - Street 1:PO BOX 8000
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75663-8000
Mailing Address - Country:US
Mailing Address - Phone:903-983-2020
Mailing Address - Fax:903-984-1567
Practice Address - Street 1:101 SIMPSON ST
Practice Address - Street 2:
Practice Address - City:GILMER
Practice Address - State:TX
Practice Address - Zip Code:75644-2231
Practice Address - Country:US
Practice Address - Phone:903-843-5400
Practice Address - Fax:903-843-5101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KILGORE-GILMER-EYE CARE CENTERS P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0193690-01Medicaid