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General NPI Number Information
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NPI Number | 1356465785
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Entity Type | Organization
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Legal Business Name | SHEBOYGAN OPTICAL CO. LLC
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 07/08/2014
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Provider Practice Location Address
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Address Line | 1442 N 31ST ST
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City | SHEBOYGAN
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State | WI
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Zip | 53081-3061
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Country | US
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Telephone | 920-458-5096
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Fax | 920-451-1085
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Provider Business Mailing Address
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Address Line | 1442 N 31ST ST
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City | SHEBOYGAN
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State | WI
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Zip | 53081-3061
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Country | US
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Telephone | 920-458-5096
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Fax | 920-451-1085
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHRISTOPHER LARSON
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Credential | M. D.
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Telephone | 920-458-5096
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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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