Provider Demographics
NPI:1114338217
Name:WILLIAM ALFRED PETTIT III MD
Entity Type:Organization
Organization Name:WILLIAM ALFRED PETTIT III MD
Other - Org Name:UNIQUE OPTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ALFRED
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:541-962-1025
Mailing Address - Street 1:1404 GEKELER LN
Mailing Address - Street 2:UNIQUE OPTIQUE
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3368
Mailing Address - Country:US
Mailing Address - Phone:541-962-6266
Mailing Address - Fax:
Practice Address - Street 1:1404 GEKELER LN
Practice Address - Street 2:UNIQUE OPTIQUE
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3368
Practice Address - Country:US
Practice Address - Phone:541-962-6266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies