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General NPI Number Information
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NPI Number | 1952482721
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Entity Type | Organization
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Legal Business Name | ROADRUNNER OPTICAL CORP
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 06/27/2014
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Provider Practice Location Address
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Address Line | 377 N MONTEZUMA ST STE 108A
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City | PRESCOTT
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State | AZ
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Zip | 86301-3020
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Country | US
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Telephone | 928-445-3808
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Fax | 928-778-3559
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Provider Business Mailing Address
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Address Line | 377 N MONTEZUMA ST STE 108A
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City | PRESCOTT
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State | AZ
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Zip | 86301-3020
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Country | US
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Telephone | 928-445-3808
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Fax | 928-778-3559
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. HEIDI BAKER
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Credential |
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Telephone | 928-445-3808
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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 | 13-046129-A
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License Number State | AZ
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