Provider Demographics
NPI:1609149731
Name:BOERNE VISION CENTER PA
Entity type:Organization
Organization Name:BOERNE VISION CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:830-331-8745
Mailing Address - Street 1:124 E BANDERA RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2849
Mailing Address - Country:US
Mailing Address - Phone:830-331-8745
Mailing Address - Fax:830-331-8749
Practice Address - Street 1:124 E BANDERA RD
Practice Address - Street 2:SUITE 403
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2849
Practice Address - Country:US
Practice Address - Phone:830-331-8745
Practice Address - Fax:830-331-8749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-21
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX376409401Medicaid