Provider Demographics
NPI:1164554903
Name:HUB OPTICAL DISTRIBUTING CO INC
Entity Type:Organization
Organization Name:HUB OPTICAL DISTRIBUTING CO INC
Other - Org Name:THE OPTICAL DISPENSARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SALGANIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-752-1081
Mailing Address - Street 1:3713 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-7329
Mailing Address - Country:US
Mailing Address - Phone:254-752-1081
Mailing Address - Fax:254-752-1463
Practice Address - Street 1:3713 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-7329
Practice Address - Country:US
Practice Address - Phone:254-752-1081
Practice Address - Fax:254-752-1463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3388T152W00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093145302Medicaid
TXTXB125858OtherMEDICARE PTAN (PHYSICIAN)
TXTXB125858OtherMEDICARE PTAN (PHYSICIAN)