Basic Information
| Provider Information | |||||||||
| NPI: | 1346552312 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAYLOR COLLEGE OF MEDICINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BCM OPTICAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 GREENWAY PLZ | ||||||||
| Address2: | SUIT E900 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770460297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137981750 | ||||||||
| FaxNumber: | 7137981144 | ||||||||
| Practice Location | |||||||||
| Address1: | 1977 BUTLER BOULEVARD | ||||||||
| Address2: | E1.108 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770304202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137982020 | ||||||||
| FaxNumber: | 7137982025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2010 | ||||||||
| LastUpdateDate: | 07/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | NICKENS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7137981750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.