Provider Demographics
NPI:1083001390
Name:UNIVERSAL OPTICAL LLC
Entity type:Organization
Organization Name:UNIVERSAL OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:JAMA
Authorized Official - Last Name:KHALIF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-250-3666
Mailing Address - Street 1:2910 PILLSBURY AVE S APT 324
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-5502
Mailing Address - Country:US
Mailing Address - Phone:612-236-4632
Mailing Address - Fax:612-259-8411
Practice Address - Street 1:2910 PILLSBURY AVE S APT 324
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-5502
Practice Address - Country:US
Practice Address - Phone:612-236-4632
Practice Address - Fax:612-259-8411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-24
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332H00000X, 332H00000X
305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No305R00000XManaged Care OrganizationsPreferred Provider Organization