Provider Demographics
NPI:1588772024
Name:OPTIMUM OPTICAL LLC
Entity type:Organization
Organization Name:OPTIMUM OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-273-2398
Mailing Address - Street 1:3930 PENDER DRIVE
Mailing Address - Street 2:SUITE #10
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-0985
Mailing Address - Country:US
Mailing Address - Phone:703-273-2398
Mailing Address - Fax:703-273-0239
Practice Address - Street 1:3930 PENDER DRIVE
Practice Address - Street 2:SUITE #10
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-0985
Practice Address - Country:US
Practice Address - Phone:703-273-2398
Practice Address - Fax:703-273-0239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101-001390156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4135090002Medicare NSC