Provider Demographics
NPI:1346419777
Name:OLDE TOWNE OPTICAL AND GIFTS LLC
Entity Type:Organization
Organization Name:OLDE TOWNE OPTICAL AND GIFTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:BA ABOC
Authorized Official - Phone:719-636-3012
Mailing Address - Street 1:3012 W COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-2147
Mailing Address - Country:US
Mailing Address - Phone:719-636-3012
Mailing Address - Fax:719-636-3014
Practice Address - Street 1:3012 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-2147
Practice Address - Country:US
Practice Address - Phone:719-636-3012
Practice Address - Fax:719-636-3014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
5631630001Medicare NSC