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General NPI Number Information
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NPI Number | 1154776672
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Entity Type | Organization
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Legal Business Name | TJSUPPER ENTERPRISES, INC. DBA THE OPTICAL SHOPPE
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Dates
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Enumeration Date | 05/03/2016
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Last Update Date | 05/03/2016
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Provider Practice Location Address
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Address Line | 180 RACE TRACK RD N UNIT 32
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City | OLDSMAR
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State | FL
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Zip | 34677-3211
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Country | US
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Telephone | 727-804-3412
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Fax | 813-855-3636
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Provider Business Mailing Address
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Address Line | 6260 31ST TER N
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City | ST PETERSBURG
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State | FL
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Zip | 33710-2402
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Country | US
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Telephone | 727-804-3412
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Fax | 727-345-5502
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Authorized Official
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Title or Position | OWNER/ OPTICIAN
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Name | TIM J. SUPPER
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Credential | DO
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Telephone | 727-804-3412
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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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