Provider Demographics
NPI:1063588374
Name:THE OPTICAL SHOP INC.
Entity type:Organization
Organization Name:THE OPTICAL SHOP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:605-692-5173
Mailing Address - Street 1:112 22ND AVE S
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2600
Mailing Address - Country:US
Mailing Address - Phone:605-692-5173
Mailing Address - Fax:605-692-6710
Practice Address - Street 1:112 22ND AVE S
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2600
Practice Address - Country:US
Practice Address - Phone:605-692-5173
Practice Address - Fax:605-692-6710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD05001EST001156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9280970Medicaid
SD=========Medicare UPIN
SD0195870001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER