Provider Demographics
NPI:1265633119
Name:OPTICAL HEADQUARTERS
Entity Type:Organization
Organization Name:OPTICAL HEADQUARTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:FUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-735-3507
Mailing Address - Street 1:1710 FREDERICKSBURG RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-5033
Mailing Address - Country:US
Mailing Address - Phone:210-735-3507
Mailing Address - Fax:210-735-1811
Practice Address - Street 1:1710 FREDERICKSBURG RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-5033
Practice Address - Country:US
Practice Address - Phone:210-735-3507
Practice Address - Fax:210-735-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTPI066132401Medicaid