Provider Demographics
NPI:1275529125
Name:TRI-STATE OPTICAL, INC.
Entity Type:Organization
Organization Name:TRI-STATE OPTICAL, INC.
Other - Org Name:CUNNINGHAM OPTICAL ONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAND
Authorized Official - Middle Name:E
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-482-1555
Mailing Address - Street 1:5600-A EAST VIRGINA STREET
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2639
Mailing Address - Country:US
Mailing Address - Phone:812-477-2020
Mailing Address - Fax:812-473-5653
Practice Address - Street 1:5600-A EAST VIRGINA STREET
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2639
Practice Address - Country:US
Practice Address - Phone:812-477-2020
Practice Address - Fax:812-473-5653
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE OPTICAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-26
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100280540AMedicaid
IN0480880002Medicare ID - Type UnspecifiedRETAIL OPTICAL