Provider Demographics
NPI:1528152709
Name:THE OPTICAL OUTLET
Entity type:Organization
Organization Name:THE OPTICAL OUTLET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LEISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-464-7387
Mailing Address - Street 1:1244 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-3861
Mailing Address - Country:US
Mailing Address - Phone:636-464-7387
Mailing Address - Fax:636-464-2613
Practice Address - Street 1:1244 MAIN ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-3861
Practice Address - Country:US
Practice Address - Phone:636-464-7387
Practice Address - Fax:636-464-2613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO16871677332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier