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General NPI Number Information
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NPI Number | 1205822145
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Entity Type | Organization
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Legal Business Name | TRI-STATE OPTICAL, INC.
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Dates
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Enumeration Date | 09/26/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5233 COLDWATER RD
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City | FORT WAYNE
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State | IN
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Zip | 46825-5538
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Country | US
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Telephone | 260-482-1555
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Fax | 260-483-8287
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Provider Business Mailing Address
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Address Line | 5233 COLDWATER RD
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City | FORT WAYNE
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State | IN
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Zip | 46825-5538
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Country | US
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Telephone | 260-482-1555
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Fax | 260-483-8287
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MR. JERRY L BRADLEY
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Credential |
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Telephone | 260-482-1555
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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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