=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669526299
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TKC OPTICAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 714 S GRAND AVE
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51301-5730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-262-3982
-----------------------------------------------------
Fax | 712-262-7831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 229 4TH ST
-----------------------------------------------------
City | SIOUX CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51101-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-252-1519
-----------------------------------------------------
Fax | 712-252-1916
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. STEVE CONLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 712-252-1519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------