1255486346 NPI number — TKC OPTICAL, INC.

Table of content: (NPI 1255486346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255486346 NPI number — TKC OPTICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TKC OPTICAL, INC.
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:
6
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:
1255486346
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:
229 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51101-1401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-252-1519
Provider Business Mailing Address Fax Number:
712-252-1916

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2510 S LOUISE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57106-4331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-361-1882
Provider Business Practice Location Address Fax Number:
605-361-5011
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CONLEY
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
712-252-1519

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  51-002 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 121515 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2100372 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21518 . This is a "SPECTERA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0070013 . This is a "BCBS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 920085 . This is a "DAKOTA CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 19006 . This is a "AVESIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9280080 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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