Healthcare Provider Details

I. General information

NPI: 1275529125
Provider Name (Legal Business Name): TRI-STATE OPTICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600-A EAST VIRGINA STREET
EVANSVILLE IN
47715-2639
US

IV. Provider business mailing address

5600-A EAST VIRGINA STREET
EVANSVILLE IN
47715-2639
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-2020
  • Fax: 812-473-5653
Mailing address:
  • Phone: 812-477-2020
  • Fax: 812-473-5653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MR. CHAND E CUNNINGHAM
Title or Position: OWNER
Credential:
Phone: 260-482-1555