MEDICARE: THE OPTICAL OUTLET

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier	16871677	MO

General Provider Information

NPI Number	:	1528152709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE OPTICAL OUTLET

Provider Business Mailing Address
First Line	:	1244 MAIN ST
Second Line	:
City	:	IMPERIAL
State	:	MO
Zip	:	63052-3861
Country	:	US
Telephone Number	:	636-464-7387
Fax Number	:	636-464-2613

Provider Business Practice Location Address
First Line	:	1244 MAIN ST
Second Line	:
City	:	IMPERIAL
State	:	MO
Zip	:	63052-3861
Country	:	US
Telephone Number	:	636-464-7387
Fax Number	:	636-464-2613

Authorized Official
Title or Position	:	OPTICIAN
Name	:	LEISA SPIKER
Credential	:
Telephone Number	:	636-464-7387

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/01/2010

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Directions to “THE OPTICAL OUTLET ” Practice Location

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