Healthcare Provider Details

I. General information

NPI: 1154776672
Provider Name (Legal Business Name): TJSUPPER ENTERPRISES, INC. DBA THE OPTICAL SHOPPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 RACE TRACK RD N UNIT 32
OLDSMAR FL
34677-3211
US

IV. Provider business mailing address

6260 31ST TER N
ST PETERSBURG FL
33710-2402
US

V. Phone/Fax

Practice location:
  • Phone: 727-804-3412
  • Fax: 813-855-3636
Mailing address:
  • Phone: 727-804-3412
  • Fax: 727-345-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: TIM J. SUPPER
Title or Position: OWNER/ OPTICIAN
Credential: DO
Phone: 727-804-3412