Healthcare Provider Details

I. General information

NPI: 1073607230
Provider Name (Legal Business Name): OPTICAL SHOP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 E MAIN ST
FESTUS MO
63028-1952
US

IV. Provider business mailing address

223 E MAIN ST
FESTUS MO
63028-1952
US

V. Phone/Fax

Practice location:
  • Phone: 636-937-2399
  • Fax: 636-937-4683
Mailing address:
  • Phone: 636-937-2399
  • Fax: 636-937-4683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number12545597
License Number StateMO

VIII. Authorized Official

Name: EDWARD SPIKER
Title or Position: OPTICIAN
Credential:
Phone: 636-937-2399