1831115005 NPI number — SPECTERA

Table of content: (NPI 1831115005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831115005 NPI number — SPECTERA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTERA
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:
UNITED OPTICAL
Provider Other Organization Name Type Code:
4
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:
1831115005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2811 LORD BALTIMORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-316-2101
Provider Business Mailing Address Fax Number:
410-265-6068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1810 OLYMPIC BOULEVARD
Provider Second Line Business Practice Location Address:
UNITED OPTICAL
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-381-1681
Provider Business Practice Location Address Fax Number:
213-381-2828
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEETER
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
VICE PRESIDENT DIRECTOR OF OPTICAL
Authorized Official Telephone Number:
443-316-2061

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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