Provider Demographics
NPI:1316071954
Name:NORTHERN LIGHTS OPTICAL
Entity type:Organization
Organization Name:NORTHERN LIGHTS OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:907-796-3937
Mailing Address - Street 1:8745 GLACIER HWY
Mailing Address - Street 2:SP. 426
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-8029
Mailing Address - Country:US
Mailing Address - Phone:907-796-3937
Mailing Address - Fax:907-796-3940
Practice Address - Street 1:8745 GLACIER HWY
Practice Address - Street 2:SP. 426
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-8029
Practice Address - Country:US
Practice Address - Phone:907-796-3937
Practice Address - Fax:907-796-3940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK305833156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOP7385Medicaid