Provider Demographics
NPI:1316416480
Name:SAPOUNAS OPTICAL GROUP, LLC
Entity Type:Organization
Organization Name:SAPOUNAS OPTICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-433-6009
Mailing Address - Street 1:228 HEATHER GLEN DR
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29316-5939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4704 SOUTH BLVD STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-2745
Practice Address - Country:US
Practice Address - Phone:561-275-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty