Basic Information
| Provider Information | |||||||||
| NPI: | 1972801223 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER LUBBOCK | ||||||||
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| OtherOrganizationName: | TEXAS TECH EYE CONSULTANTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27476 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067434263 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 4004 82ND ST BLDG 200 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794231900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067437244 | ||||||||
| FaxNumber: | 8067983391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2011 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | MAGERS | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8067431830 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 156FX1800X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | CD9207 | 01 | TX | RAILROAD MEDICARE | OTHER |