Basic Information
| Provider Information | |||||||||
| NPI: | 1336491679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARCIA-BALOK | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | CRYSTAL | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARCIA | ||||||||
| OtherFirstName: | VANESSA | ||||||||
| OtherMiddleName: | CRYSTAL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5961 S LOS ALTOS PKWY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894362500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753592020 | ||||||||
| FaxNumber: | 7753592676 | ||||||||
| Practice Location | |||||||||
| Address1: | 2413 E LOOP 820 N | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761186933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889646681 | ||||||||
| FaxNumber: | 8886620859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2012 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 825 | NV | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.