Provider Demographics
NPI:1104930411
Name:PINECREST EYE CENTER, INC
Entity type:Organization
Organization Name:PINECREST EYE CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:HALL
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:903-938-8989
Mailing Address - Street 1:405 E PINECREST DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670-7200
Mailing Address - Country:US
Mailing Address - Phone:903-938-8989
Mailing Address - Fax:903-938-9409
Practice Address - Street 1:401 E PINECREST DR UNIT A
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-7207
Practice Address - Country:US
Practice Address - Phone:903-938-8989
Practice Address - Fax:903-938-9409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000173261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH1313OtherBLUE CROSS
TX085891201Medicaid
TX451070Medicare PIN