Provider Demographics
NPI:1174034185
Name:FULL VISION OPTICAL & REPAIR
Entity type:Organization
Organization Name:FULL VISION OPTICAL & REPAIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CESAR
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:VENEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:915-226-4999
Mailing Address - Street 1:13299 MORISSEY WAY
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79928-5830
Mailing Address - Country:US
Mailing Address - Phone:915-226-4999
Mailing Address - Fax:
Practice Address - Street 1:896 HORIZON BLVD
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:TX
Practice Address - Zip Code:79927-4787
Practice Address - Country:US
Practice Address - Phone:915-226-4999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXB0115-2733152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty