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NPI Code Detail

MEDICARE: TRI-STATE OPTICAL, INC.

MEDICARE: TRI-STATE OPTICAL, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1332H00000XEyewear Supplier

General Provider Information

NPI Number : 1205822145
Entity Type Code : Organization
Provider Name (Legal Business Name) : TRI-STATE OPTICAL, INC.
Provider Business Mailing Address
First Line : 5233 COLDWATER RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46825-5538
Country : US
Telephone Number : 260-482-1555
Fax Number : 260-483-8287
Provider Business Practice Location Address
First Line : 5233 COLDWATER RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46825-5538
Country : US
Telephone Number : 260-482-1555
Fax Number : 260-483-8287
Authorized Official
Title or Position : VICE PRESIDENT
Name : MR. JERRY L BRADLEY
Credential :
Telephone Number : 260-482-1555
Provider Enumeration Date : 09/26/2005
Last Update Date : 08/22/2020

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Directions to “TRI-STATE OPTICAL, INC. ” Practice Location

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