Healthcare Provider Details

I. General information

NPI: 1740209691
Provider Name (Legal Business Name): OPTIC GALLERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 VILLAGE CENTER CIR STE 10
LAS VEGAS NV
89134-6238
US

IV. Provider business mailing address

2146 ORCHARD MIST ST
LAS VEGAS NV
89135-1562
US

V. Phone/Fax

Practice location:
  • Phone: 702-240-2121
  • Fax: 702-240-5858
Mailing address:
  • Phone: 702-869-4588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number328
License Number StateNV

VIII. Authorized Official

Name: JENNIFER C MALLINGER
Title or Position: PARTNER
Credential: O.D.
Phone: 702-240-2121