Provider Demographics
NPI:1972756880
Name:WOLFLIN VISION CLINIC, LLP
Entity type:Organization
Organization Name:WOLFLIN VISION CLINIC, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:LATTA
Authorized Official - Suffix:
Authorized Official - Credentials:OD,
Authorized Official - Phone:806-358-2205
Mailing Address - Street 1:2481 I-40 WEST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-1852
Mailing Address - Country:US
Mailing Address - Phone:806-358-2205
Mailing Address - Fax:806-463-2907
Practice Address - Street 1:2481 I-40 WEST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-1852
Practice Address - Country:US
Practice Address - Phone:806-358-2205
Practice Address - Fax:806-463-2907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T67ZOtherBLUECROSS BLUESHIELD
TX00T67ZOtherALL OTHER PLANS