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General NPI Number Information
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NPI Number | 1073607230
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Entity Type | Organization
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Legal Business Name | OPTICAL SHOP INC
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 07/01/2010
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Provider Practice Location Address
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Address Line | 223 E MAIN ST
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City | FESTUS
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State | MO
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Zip | 63028-1952
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Country | US
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Telephone | 636-937-2399
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Fax | 636-937-4683
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Provider Business Mailing Address
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Address Line | 223 E MAIN ST
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City | FESTUS
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State | MO
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Zip | 63028-1952
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Country | US
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Telephone | 636-937-2399
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Fax | 636-937-4683
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Authorized Official
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Title or Position | OPTICIAN
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Name | EDWARD SPIKER
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Credential |
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Telephone | 636-937-2399
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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 | 12545597
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License Number State | MO
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