Provider Demographics
NPI:1104004738
Name:MIDWESTERN OPTICAL
Entity Type:Organization
Organization Name:MIDWESTERN OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-692-3754
Mailing Address - Street 1:3010 MIDWESTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2835
Mailing Address - Country:US
Mailing Address - Phone:940-692-3754
Mailing Address - Fax:940-696-2148
Practice Address - Street 1:3010 MIDWESTERN PKWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2835
Practice Address - Country:US
Practice Address - Phone:940-692-3754
Practice Address - Fax:940-696-2148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3986150001Medicare NSC