=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952521510
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OP-TECH LABORATORY COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1817 LELARAY ST
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80909-2801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-632-2875
-----------------------------------------------------
Fax | 719-471-2159
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1817 LELARAY ST
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80909-2801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-632-2875
-----------------------------------------------------
Fax | 719-471-2159
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY-TREASURER
-----------------------------------------------------
Name | KATHLEEN D KELLY
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 719-632-2875
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------