Provider Demographics
NPI:1487380457
Name:COLLEGE STATION VISION CENTER PLLC
Entity type:Organization
Organization Name:COLLEGE STATION VISION CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:432-413-1997
Mailing Address - Street 1:4018 HERU CT
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-7085
Mailing Address - Country:US
Mailing Address - Phone:432-413-1997
Mailing Address - Fax:
Practice Address - Street 1:4321 STATE HIGHWAY 6 SOUTH
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845
Practice Address - Country:US
Practice Address - Phone:979-321-6565
Practice Address - Fax:979-321-6566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty