1497190581 NPI number — THE OPTICAL SHOPPE PLLC

Table of content: (NPI 1497190581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497190581 NPI number — THE OPTICAL SHOPPE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE OPTICAL SHOPPE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497190581
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 N LOWRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMYRNA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37167-2525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-459-0675
Provider Business Mailing Address Fax Number:
615-459-6401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 N LOWRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37167-2525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-459-0675
Provider Business Practice Location Address Fax Number:
615-459-6401
Provider Enumeration Date:
05/03/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TRAPENI
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
615-459-0675

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  ODT941 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0071007 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".