Provider Demographics
NPI:1073509923
Name:TRISTATE OPTICAL, INC.
Entity Type:Organization
Organization Name:TRISTATE OPTICAL, INC.
Other - Org Name:CUNNINGHAM OPTICAL ONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-269-2223
Mailing Address - Street 1:2932 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3914
Mailing Address - Country:US
Mailing Address - Phone:574-269-2223
Mailing Address - Fax:574-269-3088
Practice Address - Street 1:2932 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3914
Practice Address - Country:US
Practice Address - Phone:574-269-2223
Practice Address - Fax:574-269-3088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0480880003Medicare ID - Type UnspecifiedRETAIL OPTICAL