1154776672 NPI number — TJSUPPER ENTERPRISES, INC. DBA THE OPTICAL SHOPPE

Table of content: (NPI 1154776672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154776672 NPI number — TJSUPPER ENTERPRISES, INC. DBA THE OPTICAL SHOPPE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TJSUPPER ENTERPRISES, INC. DBA THE OPTICAL SHOPPE
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:
1154776672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6260 31ST TER N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33710-2402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-804-3412
Provider Business Mailing Address Fax Number:
727-345-5502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 RACE TRACK RD N UNIT 32
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLDSMAR
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34677-3211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-804-3412
Provider Business Practice Location Address Fax Number:
813-855-3636
Provider Enumeration Date:
05/03/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SUPPER
Authorized Official First Name:
TIM
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER/ OPTICIAN
Authorized Official Telephone Number:
727-804-3412

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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