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General NPI Number Information
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NPI Number | 1013522010
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Entity Type | Organization
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Legal Business Name | WESTERN STATES OPTICAL, INC.
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Dates
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Enumeration Date | 09/15/2020
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Last Update Date | 07/03/2024
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Provider Practice Location Address
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Address Line | 1268 INTERQUEST PKWY STE 120
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City | COLORADO SPRINGS
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State | CO
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Zip | 80921-4209
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Country | US
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Telephone | 719-639-7014
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Fax |
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Provider Business Mailing Address
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Address Line | 1268 INTERQUEST PKWY STE 120
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City | COLORADO SPRINGS
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State | CO
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Zip | 80921-4209
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Country | US
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Telephone | 540-424-6921
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Fax |
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Authorized Official
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Title or Position | LICENSED OPERATOR
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Name | MR. ROBERT LEE WALTERS
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Credential |
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Telephone | 540-424-6921
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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