Provider Demographics
NPI:1194914010
Name:SPECIALIZED OPTICAL COMPANY
Entity type:Organization
Organization Name:SPECIALIZED OPTICAL COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAUSSE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:801-393-9440
Mailing Address - Street 1:5735 HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4324
Mailing Address - Country:US
Mailing Address - Phone:801-393-9440
Mailing Address - Fax:
Practice Address - Street 1:5735 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4324
Practice Address - Country:US
Practice Address - Phone:801-393-9440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier