Provider Demographics
NPI:1073658290
Name:THE OPTICAL SHOP OF WEST CLAY INC
Entity Type:Organization
Organization Name:THE OPTICAL SHOP OF WEST CLAY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:TROUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-947-0207
Mailing Address - Street 1:2127 BLUESTONE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6709
Mailing Address - Country:US
Mailing Address - Phone:636-947-0207
Mailing Address - Fax:636-947-5996
Practice Address - Street 1:2127 BLUESTONE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-6709
Practice Address - Country:US
Practice Address - Phone:636-947-0207
Practice Address - Fax:636-947-5996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0591780001Medicare NSC
MA3741Medicare PIN