Provider Demographics
NPI:1699951756
Name:OAK CREEK OPTICAL
Entity type:Organization
Organization Name:OAK CREEK OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:A
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:GROSSNICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-785-0443
Mailing Address - Street 1:2615 NE LOOP 286
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-3444
Mailing Address - Country:US
Mailing Address - Phone:903-785-0443
Mailing Address - Fax:903-785-2947
Practice Address - Street 1:2615 NE LOOP 286
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-3444
Practice Address - Country:US
Practice Address - Phone:903-785-0443
Practice Address - Fax:903-785-2947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6388332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1100976-02Medicaid
TXB23146Medicare UPIN
TX1100976-02Medicaid