=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649485483
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SG OPTICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 02/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2210 IDAHO ST
-----------------------------------------------------
City | ELKO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89801-2643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-738-6727
-----------------------------------------------------
Fax | 775-753-6452
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2210 IDAHO ST
-----------------------------------------------------
City | ELKO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89801-2643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-738-6727
-----------------------------------------------------
Fax | 775-753-6452
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | THOMAS LEAVERTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-738-6727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 524
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------