Provider Demographics
NPI:1346066024
Name:BLACK, ALICE SEAVON (OPTHALMIC ASSISTANT)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:SEAVON
Last Name:BLACK
Suffix:
Gender:F
Credentials:OPTHALMIC ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:428 CENTENNIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-7166
Mailing Address - Country:US
Mailing Address - Phone:903-266-5990
Mailing Address - Fax:903-266-5970
Practice Address - Street 1:428 CENTENNIAL PKWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-7166
Practice Address - Country:US
Practice Address - Phone:903-266-5900
Practice Address - Fax:903-266-5914
Is Sole Proprietor?:No
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX190956156FX1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant