Southlake Vision Group PLLC
Optometrist in Southlake, TX. Organization (NPI-2).
NPI number1114438017
StatusActive
Last updated in NPPESDec 1, 2017
Details
- NPI
- 1114438017
- Entity type
- Organization (NPI-2)
- Legal business name
- Southlake Vision Group PLLC
- Organization subpart
- No
- Enumeration date
- Oct 18, 2017
- Last updated
- Dec 1, 2017
Medicare and OIG
- Medicare enrolled (PECOS)
- Yes · PART B SUPPLIER - CLINIC/GROUP PRACTICE
- Can order and refer
- Not on the CMS order and referring list
- OIG exclusion list
- This NPI is not listed
CMS and OIG files of November 2026. PECOS lookup · OIG exclusion check
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 152W00000X | Optometrist | – | – | Yes |
Practice location
3004 E Southlake BlvdSouthlake, TX 76092-6618
Phone 682-554-2079
Mailing address
1104 Guadalupe CtColleyville, TX 76034-5885
Phone 682-554-2079
Authorized official
Yury Ronin
Optometrist
6825542079
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