Provider Demographics
NPI:1104002328
Name:MUSTANG OPTICAL, INC.
Entity Type:Organization
Organization Name:MUSTANG OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNITH
Authorized Official - Middle Name:D
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-376-0222
Mailing Address - Street 1:123 N MUSTANG RD
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-3912
Mailing Address - Country:US
Mailing Address - Phone:405-376-0222
Mailing Address - Fax:405-376-0233
Practice Address - Street 1:123 N MUSTANG RD
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-3912
Practice Address - Country:US
Practice Address - Phone:405-376-0222
Practice Address - Fax:405-376-0233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100769000AMedicaid
OK0706760001Medicare NSC