Healthcare Provider Details

I. General information

NPI: 1144209172
Provider Name (Legal Business Name): SUNLAND OPTICAL CO., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 REPLACEMENT AVE BLD 487
FORT LEONARD WOOD MO
65473
US

IV. Provider business mailing address

1156 BARRANCA DR
EL PASO TX
79935-5095
US

V. Phone/Fax

Practice location:
  • Phone: 573-329-4860
  • Fax:
Mailing address:
  • Phone: 915-591-9483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1201X
TaxonomyOptometric Assistant Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: YVONNE BERNAL
Title or Position: CONTROLLER
Credential:
Phone: 915-591-9483