Provider Demographics
NPI:1194728337
Name:MOCKINGBIRD OPTICAL SHOP LLC
Entity type:Organization
Organization Name:MOCKINGBIRD OPTICAL SHOP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:C
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-340-1212
Mailing Address - Street 1:5430 FREDERICKSBURG RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3539
Mailing Address - Country:US
Mailing Address - Phone:210-340-1212
Mailing Address - Fax:210-525-9617
Practice Address - Street 1:5430 FREDERICKSBURG RD
Practice Address - Street 2:STE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3539
Practice Address - Country:US
Practice Address - Phone:210-340-1212
Practice Address - Fax:210-525-9617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4487710001332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4487710001Medicare NSC