1508920299 NPI number — IDEAL OPTICAL INC

Table of content: (NPI 1508920299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508920299 NPI number — IDEAL OPTICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDEAL 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:
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:
1508920299
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:
6873A NORTH 9TH AVE
Provider Second Line Business Mailing Address:
IDEAL OPTICAL INC
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32504-7349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-477-0582
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6873A NORTH 9TH AVE
Provider Second Line Business Practice Location Address:
IDEAL OPTICAL INC
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504-7349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-477-0582
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PUTNAM
Authorized Official First Name:
FRED
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
850-477-0582

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D5664 . This is a "FLORIDA BS" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com