Provider Demographics
NPI:1053974741
Name:TRINA LIESKE O.D., FCOVD, P.A.
Entity type:Organization
Organization Name:TRINA LIESKE O.D., FCOVD, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIESKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-271-8563
Mailing Address - Street 1:4257 SAN SIMEON LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-6803
Mailing Address - Country:US
Mailing Address - Phone:817-456-4031
Mailing Address - Fax:
Practice Address - Street 1:5412 BOAT CLUB RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-1206
Practice Address - Country:US
Practice Address - Phone:817-546-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-17
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty