Provider Demographics
NPI:1154682466
Name:PROFESSIONAL OPTICAL
Entity Type:Organization
Organization Name:PROFESSIONAL OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCOLLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:719-471-3937
Mailing Address - Street 1:525 N TEJON ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1109
Mailing Address - Country:US
Mailing Address - Phone:719-471-3937
Mailing Address - Fax:
Practice Address - Street 1:525 N TEJON ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1109
Practice Address - Country:US
Practice Address - Phone:719-471-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier