Basic Information
| Provider Information | |||||||||
| NPI: | 1457314528 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCOTT & WHITE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848496 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752848496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1815 S 31ST ST | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765046728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242020 | ||||||||
| FaxNumber: | 2547249571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 03/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | CANTU | ||||||||
| AuthorizedOfficialFirstName: | ALICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOCIATE VP, RCO | ||||||||
| AuthorizedOfficialTelephone: | 2542159719 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SCOTT & WHITE OPTICAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 1598088-01 | 05 | TX | MEDICAID | 4356110003 | 01 | TX | RR/MEDICARE | OTHER |