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General NPI Number Information
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NPI Number | 1205103215
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Entity Type | Organization
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Legal Business Name | 20-10 OPTICAL, LLC
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Dates
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Enumeration Date | 11/18/2011
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Last Update Date | 11/18/2011
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Provider Practice Location Address
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Address Line | 121 E MARION AVE SUITE 111
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City | PUNTA GORDA
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State | FL
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Zip | 33950-3635
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Country | US
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Telephone | 941-833-9044
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Fax |
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Provider Business Mailing Address
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Address Line | 121 E MARION AVE SUITE 111
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City | PUNTA GORDA
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State | FL
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Zip | 33950-3635
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MGRM
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Name | JAMES DAVIS MUNGENAST
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Credential | L.D.O.
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Telephone | 941-833-9044
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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 | OE 1978
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License Number State | FL
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