Provider Demographics
NPI:1265043038
Name:GWA OPTICAL LLC
Entity Type:Organization
Organization Name:GWA OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-557-9004
Mailing Address - Street 1:3601 SW 160TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6312
Mailing Address - Country:US
Mailing Address - Phone:305-557-9004
Mailing Address - Fax:
Practice Address - Street 1:11 E 75TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-1601
Practice Address - Country:US
Practice Address - Phone:305-557-9004
Practice Address - Fax:885-881-9434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier