Healthcare Provider Details

I. General information

NPI: 1164053005
Provider Name (Legal Business Name): MNG OPTICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 CLEAR CREEK DR
OSPREY FL
34229-6814
US

IV. Provider business mailing address

674 CLEAR CREEK DR
OSPREY FL
34229-6814
US

V. Phone/Fax

Practice location:
  • Phone: 309-749-8837
  • Fax:
Mailing address:
  • Phone: 309-749-8837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: VITALII KHODZHAIEV
Title or Position: CEO
Credential:
Phone: 309-749-8837