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General NPI Number Information
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NPI Number | 1902979792
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Entity Type | Organization
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Legal Business Name | CERTIFIED CC OPTICIANS
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1173 E 42ND STREET
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City | ODESSA
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State | TX
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Zip | 79762
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Country | US
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Telephone | 432-367-9401
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Fax | 432-362-2327
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Provider Business Mailing Address
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Address Line | 1173 E 42ND STREET
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City | ODESSA
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State | TX
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Zip | 79762
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Country | US
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Telephone | 432-367-9401
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Fax | 432-362-2327
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Authorized Official
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Title or Position | OPTICIAN OWNER
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Name | MR. TERRY LYNN COOK
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Credential |
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Telephone | 432-367-9401
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | ABO3472
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License Number State | TX
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