Provider Demographics
NPI:1386601631
Name:COLUMBUS OPTICAL COMPANY, LTD.
Entity type:Organization
Organization Name:COLUMBUS OPTICAL COMPANY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-732-5771
Mailing Address - Street 1:100 SWEETBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:TX
Mailing Address - Zip Code:78934-3008
Mailing Address - Country:US
Mailing Address - Phone:979-732-5771
Mailing Address - Fax:979-732-6922
Practice Address - Street 1:108 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-2627
Practice Address - Country:US
Practice Address - Phone:979-968-3953
Practice Address - Fax:979-968-3435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141463305Medicaid
3977340001Medicare PIN
TX141463305Medicaid